Healthcare Provider Details

I. General information

NPI: 1881609204
Provider Name (Legal Business Name): KANDICE M. KOWALEWSKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 JAMES ST SUITE 100
SYRACUSE NY
13203-2117
US

IV. Provider business mailing address

792 N MAIN ST SUITE 100A
NORTH SYRACUSE NY
13212-1644
US

V. Phone/Fax

Practice location:
  • Phone: 315-422-2222
  • Fax: 315-472-8497
Mailing address:
  • Phone: 315-423-9722
  • Fax: 315-423-9687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0098221
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: