Provider Demographics
NPI:1023147535
Name:KOSIBA, ANDREW EDWARD (DPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:EDWARD
Last Name:KOSIBA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 S WESTYN LOOP
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-5078
Mailing Address - Country:US
Mailing Address - Phone:631-495-9968
Mailing Address - Fax:
Practice Address - Street 1:1017 S WESTYN LOOP
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-5078
Practice Address - Country:US
Practice Address - Phone:631-495-9968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015470225100000X
VA2305214907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQL1971Medicare UPIN