Provider Demographics
NPI:1861938854
Name:ROZEK, KATHERINE L (PA)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:L
Last Name:ROZEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:L
Other - Last Name:DUNTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-985-4632
Mailing Address - Fax:269-985-4535
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-985-4632
Practice Address - Fax:269-985-4535
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN