Provider Demographics
NPI:1154169035
Name:KOZAR, NINA ELISABETH
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:ELISABETH
Last Name:KOZAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 S CENTRE AVE STE A3
Mailing Address - Street 2:
Mailing Address - City:LEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:19533-8661
Mailing Address - Country:US
Mailing Address - Phone:610-926-8352
Mailing Address - Fax:
Practice Address - Street 1:5 S CENTRE AVE STE A3
Practice Address - Street 2:
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533-8661
Practice Address - Country:US
Practice Address - Phone:610-926-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA006929363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical