Provider Demographics
NPI:1922536820
Name:KOVACIK, LAURA SUSANNE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:SUSANNE
Last Name:KOVACIK
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:ROSSFORD
Mailing Address - State:OH
Mailing Address - Zip Code:43460-1512
Mailing Address - Country:US
Mailing Address - Phone:419-304-0692
Mailing Address - Fax:
Practice Address - Street 1:6005 MONCLOVA RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1864
Practice Address - Country:US
Practice Address - Phone:419-893-2663
Practice Address - Fax:419-893-7240
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant