Healthcare Provider Details

I. General information

NPI: 1023615267
Provider Name (Legal Business Name): VICTORIA MARIE KOWALENKO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S CLAY ST
ENNIS TX
75119-5771
US

IV. Provider business mailing address

7425 LA VISTA DR APT 234
DALLAS TX
75214-4280
US

V. Phone/Fax

Practice location:
  • Phone: 972-875-5220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: