Healthcare Provider Details

I. General information

NPI: 1548593643
Provider Name (Legal Business Name): LAURA C KOZOL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06106-3300
US

IV. Provider business mailing address

80 SEYMOUR ST
HARTFORD CT
06106-3300
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-2795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9108403
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3809
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3237
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: