Provider Demographics
NPI:1427049139
Name:KOWALCHUK, MARY K (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:KOWALCHUK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 COMMERCE LANE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3739
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-386-1410
Practice Address - Street 1:155 FINNEY BLVD.
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1067
Practice Address - Country:US
Practice Address - Phone:518-483-0109
Practice Address - Fax:518-483-0201
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NY009127363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
NYAA0564Medicare PIN