Healthcare Provider Details

I. General information

NPI: 1922577568
Provider Name (Legal Business Name): COURTNEY A KOVACIC PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY STEFANIK PA

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8643 SHERIDAN DR
WILLIAMSVILLE NY
14221-6315
US

IV. Provider business mailing address

8205 MAIN ST STE 14
WILLIAMSVILLE NY
14221-6054
US

V. Phone/Fax

Practice location:
  • Phone: 716-565-9030
  • Fax:
Mailing address:
  • Phone: 716-539-0789
  • Fax: 716-250-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number022997
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: