Healthcare Provider Details

I. General information

NPI: 1477658235
Provider Name (Legal Business Name): MARCI ANN KOWALEWSKI PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 CARBONDALE RD BOX Z
WAYMART PA
18472
US

IV. Provider business mailing address

512 HILLSIDE STREET
RICHMONDALE PA
18421
US

V. Phone/Fax

Practice location:
  • Phone: 570-488-5444
  • Fax: 570-488-6666
Mailing address:
  • Phone: 570-785-9373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0A000262L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA001229L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: