Healthcare Provider Details

I. General information

NPI: 1720842917
Provider Name (Legal Business Name): COLIN THOMAS GWIAZDOWSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 WALNUT ST
EVANSVILLE IN
47708-1621
US

IV. Provider business mailing address

220 N MAIN ST #221
EVANSVILLE IN
78660
US

V. Phone/Fax

Practice location:
  • Phone: 812-909-7200
  • Fax:
Mailing address:
  • Phone: 610-781-3068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: