Healthcare Provider Details

I. General information

NPI: 1104720762
Provider Name (Legal Business Name): COURTNEY KACZMAREK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 MAIN ST
WINTERSVILLE OH
43953-3734
US

IV. Provider business mailing address

130 MARIE AVE
WEIRTON WV
26062-2936
US

V. Phone/Fax

Practice location:
  • Phone: 740-346-2702
  • Fax:
Mailing address:
  • Phone: 304-919-3417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: