Healthcare Provider Details

I. General information

NPI: 1023434552
Provider Name (Legal Business Name): KODI VEALE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 EMBASSY PKWY
AKRON OH
44333-8320
US

IV. Provider business mailing address

3975 EMBASSY PKWY
AKRON OH
44333-8320
US

V. Phone/Fax

Practice location:
  • Phone: 330-668-4040
  • Fax: 330-668-4078
Mailing address:
  • Phone: 330-668-4040
  • Fax: 330-668-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.004003RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50.004003
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: