Basic Information
| Provider Information | |||||||||
| NPI: | 1255474581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZOSEL | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | MS PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52194 | ||||||||
| Address2: | DEPT CODE 960 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850722194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034891781 | ||||||||
| FaxNumber: | 5034891650 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 N IVY ST | ||||||||
| Address2: | |||||||||
| City: | CANBY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970133704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032636786 | ||||||||
| FaxNumber: | 5032636451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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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 | 225100000X | 4979 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 278083 | 05 | OR | MEDICAID |