Healthcare Provider Details

I. General information

NPI: 1063595437
Provider Name (Legal Business Name): BRYAN CHRISTOPHER KOZAK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2006
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10207 CERNY ST STE 312
RALEIGH NC
27617-4887
US

IV. Provider business mailing address

10207 CERNY ST STE 312
RALEIGH NC
27617-4887
US

V. Phone/Fax

Practice location:
  • Phone: 919-660-8346
  • Fax: 919-668-2563
Mailing address:
  • Phone: 919-660-8346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1073875
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06354
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: