=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801769906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAGDALENA AGNIESZKA KOTLARZ PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2025
-----------------------------------------------------
Last Update Date | 09/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16001 W 9 MILE RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-4818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-536-2127
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13309 LEDWON ST
-----------------------------------------------------
City | SHELBY TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601013337
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------