Healthcare Provider Details

I. General information

NPI: 1508424953
Provider Name (Legal Business Name): BRETT ALLEN KOTOWSKI AGPCNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 N CAPITOL AVE
INDIANAPOLIS IN
46202-1222
US

IV. Provider business mailing address

909 RIDGEBROOK RD STE 300
SPARKS GLENCOE MD
21152-9477
US

V. Phone/Fax

Practice location:
  • Phone: 317-924-5821
  • Fax:
Mailing address:
  • Phone: 443-483-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number28230200A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: