1770878779 NPI number — PAULA AUGUSTINA KOSBERG

Table of content: PAULA AUGUSTINA KOSBERG (NPI 1770878779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770878779 NPI number — PAULA AUGUSTINA KOSBERG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSBERG
Provider First Name:
PAULA
Provider Middle Name:
AUGUSTINA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

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 Information

NPI Number:
1770878779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11481 SW HALL BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 E PARKCENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83706-6662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-336-8433
Provider Business Practice Location Address Fax Number:
208-336-8441
Provider Enumeration Date:
06/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2853 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1770878779 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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