Healthcare Provider Details

I. General information

NPI: 1235736448
Provider Name (Legal Business Name): KAROLINA MARIA KOWALCZYK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 BEACON ST APT 3D
BROOKLINE MA
02446-3974
US

IV. Provider business mailing address

1110 BEACON ST APT 3D
BROOKLINE MA
02446-3974
US

V. Phone/Fax

Practice location:
  • Phone: 203-559-2386
  • Fax:
Mailing address:
  • Phone: 203-559-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1167107
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: