Healthcare Provider Details

I. General information

NPI: 1093111551
Provider Name (Legal Business Name): JOHN KOZLIK II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 MILITIA DR
JEFFERSON CITY MO
65101-1203
US

IV. Provider business mailing address

GENERAL LEONARD WOOD COMMUNITY HOSPITAL 4234 ILLINOIS AVE.
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 573-638-9530
  • Fax:
Mailing address:
  • Phone: 573-596-0039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA170500
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: