Healthcare Provider Details

I. General information

NPI: 1629074505
Provider Name (Legal Business Name): JAN IDZIKOWSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 COUNTY RD
NEW LONDON NH
03257-5736
US

IV. Provider business mailing address

273 COUNTY RD
NEW LONDON NH
03257-5736
US

V. Phone/Fax

Practice location:
  • Phone: 603-526-2911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number585
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1188
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: