Healthcare Provider Details

I. General information

NPI: 1144683707
Provider Name (Legal Business Name): ANDREW KOWALSKI RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date: 11/14/2018
Reactivation Date: 01/15/2020

III. Provider practice location address

263 BLUE POINT AVE
BLUE POINT NY
11715-1224
US

IV. Provider business mailing address

263 BLUE POINT AVE
BLUE POINT NY
11715-1224
US

V. Phone/Fax

Practice location:
  • Phone: 631-419-6737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number697762
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: