Provider Demographics
NPI:1659040020
Name:KOZLOW, MAUREEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:KOZLOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:
Practice Address - Street 1:1500 S LAKE PARK AVE STE 110
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:219-947-6017
Practice Address - Fax:219-947-6018
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN00000000A363A00000X
IN10003398A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300054941Medicaid