Healthcare Provider Details

I. General information

NPI: 1144263104
Provider Name (Legal Business Name): MICHAEL KUCZKOWSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204
US

IV. Provider business mailing address

PO BOX 863026
ORLANDO FL
32886-3026
US

V. Phone/Fax

Practice location:
  • Phone: 904-308-8435
  • Fax: 904-346-0113
Mailing address:
  • Phone: 800-288-8325
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA0002852
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2852
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: