Healthcare Provider Details

I. General information

NPI: 1427049139
Provider Name (Legal Business Name): MARY K KOWALCHUK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 FINNEY BLVD.
MALONE NY
12953-1067
US

IV. Provider business mailing address

4 COMMERCE LANE
CANTON NY
13617-3739
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-0109
  • Fax: 518-483-0201
Mailing address:
  • Phone: 315-386-8191
  • Fax: 315-386-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number009127
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: