Provider Demographics
NPI:1487616363
Name:KOSZAREK, MARY JO (NP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JO
Last Name:KOSZAREK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-2040
Mailing Address - Country:US
Mailing Address - Phone:218-879-0977
Mailing Address - Fax:
Practice Address - Street 1:927 TRETTEL LN
Practice Address - Street 2:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1345
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:218-878-2188
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-130517-3363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN699316800Medicaid
MN699316800Medicaid
FMS52290Medicare UPIN