Healthcare Provider Details

I. General information

NPI: 1659343275
Provider Name (Legal Business Name): HENRY RICHARD COZINE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 GARRISON AVE
PORT ST JOE FL
32456-5265
US

IV. Provider business mailing address

2024 INDIAN PASS RD
PORT ST JOE FL
32456-7816
US

V. Phone/Fax

Practice location:
  • Phone: 850-227-1276
  • Fax: 850-227-1794
Mailing address:
  • Phone: 850-227-1276
  • Fax: 850-227-1794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2182
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: