Healthcare Provider Details

I. General information

NPI: 1164528568
Provider Name (Legal Business Name): SUSAN R KOWALL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 LEONARD AVE BUILDING #1 SUITE 300
WASHINGTON PA
15301-3368
US

IV. Provider business mailing address

125 MARKWOOD DR
CANONSBURG PA
15317-8531
US

V. Phone/Fax

Practice location:
  • Phone: 724-225-3640
  • Fax:
Mailing address:
  • Phone: 412-855-9576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00939
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA050955
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: