Healthcare Provider Details

I. General information

NPI: 1073172003
Provider Name (Legal Business Name): ABOLFAZL KOWSARI CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: FAZY KOWSARI CNP

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9512 PINEVIEW LN N
MAPLE GROVE MN
55369-7135
US

IV. Provider business mailing address

9512 PINEVIEW LN N
MAPLE GROVE MN
55369-7135
US

V. Phone/Fax

Practice location:
  • Phone: 763-923-5608
  • Fax:
Mailing address:
  • Phone: 763-923-5608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6617
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: