Provider Demographics
NPI:1033753546
Name:KOSTREBA, KELSEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KOSTREBA
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Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9825 HOSPITAL DR STE 105
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4769
Mailing Address - Country:US
Mailing Address - Phone:763-780-6699
Mailing Address - Fax:763-420-0500
Practice Address - Street 1:9825 HOSPITAL DR STE 105
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4769
Practice Address - Country:US
Practice Address - Phone:763-780-6699
Practice Address - Fax:763-420-0500
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-11-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN13172363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical