1598833493 NPI number — AI LIEN KOWALSKI CRNA

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598833493 NPI number — AI LIEN KOWALSKI CRNA

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

KOWALSKI

Provider First Name:

AI LIEN

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

CRNA

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1598833493

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/23/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

11438 FRESHWATER RIDGE DR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

RIVERVIEW

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33569-2060

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

502-424-3867

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

100 MALLARD CREEK RD

Provider Second Line Business Practice Location Address:

SUITE 320

Provider Business Practice Location Address City Name:

LOUISVILLE

Provider Business Practice Location Address State Name:

KY

Provider Business Practice Location Address Postal Code:

40207-4194

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

502-690-8782

Provider Business Practice Location Address Fax Number:

502-459-0923

Provider Enumeration Date:

12/01/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 163W00000X , with the licence number:  1092643 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363L00000X , with the licence number: 3005008 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 367500000X , with the licence number: 3005008 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 367500000X , with the licence number: 403331-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 7100046960 . This is a "MEDICAID- NURSE PRACTITIONER PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 000000774820 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: P01076180 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 7100215970 . This is a "MEDICAID- NURSE ANESTHETIST PROVIDER NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 50040406 . This is a "PASSPORT HEALTH PLAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 200955570 . This is a "MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
• Identifier: 015111600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".