Provider Demographics
NPI:1770644817
Name:KORCZYKOWSKI, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KORCZYKOWSKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SHAMROCK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-5801
Mailing Address - Country:US
Mailing Address - Phone:802-338-3553
Mailing Address - Fax:802-338-3532
Practice Address - Street 1:141 SHAMROCK RD
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-5801
Practice Address - Country:US
Practice Address - Phone:802-338-3553
Practice Address - Fax:802-338-3532
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550031038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant