Provider Demographics
NPI:1659769354
Name:KODZODZIKU, FATBARDHA (PA)
Entity Type:Individual
Prefix:MRS
First Name:FATBARDHA
Middle Name:
Last Name:KODZODZIKU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5429
Mailing Address - Country:US
Mailing Address - Phone:203-340-9611
Mailing Address - Fax:
Practice Address - Street 1:1 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5429
Practice Address - Country:US
Practice Address - Phone:203-340-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-03
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3227363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical