Healthcare Provider Details

I. General information

NPI: 1639560626
Provider Name (Legal Business Name): KAYLA KOZA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 05/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 TAMARACK AVE STE 104
SOUTH WINDSOR CT
06074-5553
US

IV. Provider business mailing address

2800 TAMARACK AVE STE 104
SOUTH WINDSOR CT
06074-5553
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-1222
  • Fax:
Mailing address:
  • Phone: 860-533-4695
  • Fax: 860-648-0013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3279
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: