Basic Information
| Provider Information | |||||||||
| NPI: | 1679124861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOGAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20301 NE 30TH AVE APT 212 | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331801572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862804761 | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 NW 53RD ST STE 330 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334878281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004880279 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2019 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9112615 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9112615 | 01 | FL | PA LICENSE NUMBER | OTHER |