Basic Information
Provider Information | |||||||||
NPI: | 1881649341 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOSANOVICH | ||||||||
FirstName: | FELICIA | ||||||||
MiddleName: | HOPE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 POWELL STREET | ||||||||
Address2: | STE 920 | ||||||||
City: | EMERYVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 946081803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103502654 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 GRANT ROAD | ||||||||
Address2: |   | ||||||||
City: | MOUNTAIN VIEW | ||||||||
State: | CA | ||||||||
PostalCode: | 94040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6509407055 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 11/26/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA16738 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.