Basic Information
Provider Information | |||||||||
NPI: | 1780082313 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOSHY | ||||||||
FirstName: | MERLYN | ||||||||
MiddleName: | JACOB | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JACOB | ||||||||
OtherFirstName: | MERLYN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
Address2: |   | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149013230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6072712050 | ||||||||
FaxNumber: | 6078731244 | ||||||||
Practice Location | |||||||||
Address1: | 600 ROE AVENUE | ||||||||
Address2: |   | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149051629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077374508 | ||||||||
FaxNumber: | 6077355738 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2014 | ||||||||
LastUpdateDate: | 11/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00351600 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 018251 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 103367085 | 05 | PA |   | MEDICAID | 04342201 | 05 | NY |   | MEDICAID |