Healthcare Provider Details

I. General information

NPI: 1154885770
Provider Name (Legal Business Name): MR. TIMOTHY KOZEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FAIRFIELD DR
SENECA PA
16346-2130
US

IV. Provider business mailing address

2928 LENA CT
ERIE PA
16506-1348
US

V. Phone/Fax

Practice location:
  • Phone: 814-676-7600
  • Fax:
Mailing address:
  • Phone: 814-671-3661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN649354
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN649354
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: