Healthcare Provider Details

I. General information

NPI: 1427598119
Provider Name (Legal Business Name): MARK JEFFREY KOWALCYK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9612 SE HIGHBORNE WAY
HOBE SOUND FL
33455-6828
US

IV. Provider business mailing address

9612 SE HIGHBORNE WAY
HOBE SOUND FL
33455-6828
US

V. Phone/Fax

Practice location:
  • Phone: 561-529-0322
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberGAA-CRNA002130
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9335901
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: