Provider Demographics
NPI:1861047391
Name:KOVACH, DUSTIN ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:ANTHONY
Last Name:KOVACH
Suffix:
Gender:M
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 1:8251 COLUMBINE RD
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7610
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:8251 COLUMBINE RD
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7610
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN13123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant