Provider Demographics
NPI:1336523968
Name:KUZNICKI, GARY J (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:KUZNICKI
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3003 W DR MLK BLVD FL JR3
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6307
Mailing Address - Country:US
Mailing Address - Phone:813-554-8983
Mailing Address - Fax:813-443-8177
Practice Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:MAB-3RD FLOOR
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-554-8983
Practice Address - Fax:813-443-8177
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108861363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015632100Medicaid