Healthcare Provider Details

I. General information

NPI: 1124513114
Provider Name (Legal Business Name): GINA S. KOZUL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18555 N 79TH AVE BLDG C
GLENDALE AZ
85308-8370
US

IV. Provider business mailing address

7301 N 16TH ST STE 102
PHOENIX AZ
85020-5266
US

V. Phone/Fax

Practice location:
  • Phone: 623-776-2500
  • Fax:
Mailing address:
  • Phone: 480-420-4027
  • Fax: 602-535-0640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1540
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: