Provider Demographics
NPI:1255716825
Name:KOZAK, KELLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:KOZAK
Suffix:
Gender:
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 1:1001 SHEPPARD RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4796
Mailing Address - Country:US
Mailing Address - Phone:817-946-6960
Mailing Address - Fax:
Practice Address - Street 1:1605 E EVESHAM RD STE 201
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-1437
Practice Address - Country:US
Practice Address - Phone:856-565-2900
Practice Address - Fax:856-565-2901
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA066072363A00000X
NJ25MP00883700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX470260YKQLMedicare PIN