Basic Information
| Provider Information | |||||||||
| NPI: | 1770878779 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KOSBERG | ||||||||
| FirstName: | PAULA | ||||||||
| MiddleName: | AUGUSTINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 E PARKCENTER BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837066662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368433 | ||||||||
| FaxNumber: | 2083368441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2011 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
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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 | 2853 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1770878779 | 05 | ID | MEDICAID |