Healthcare Provider Details

I. General information

NPI: 1346203072
Provider Name (Legal Business Name): CHESTER B. KOZAK II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 S 4TH ST
LEAVENWORTH KS
66048-5014
US

IV. Provider business mailing address

1530 SOUTHERN HILLS TER
LANSING KS
66043-6202
US

V. Phone/Fax

Practice location:
  • Phone: 913-682-2000
  • Fax: 913-758-4185
Mailing address:
  • Phone: 913-250-0334
  • Fax: 913-250-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00271
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: