Provider Demographics
NPI:1063011922
Name:ALCOSEBA, EDEN
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:ALCOSEBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 WOLF RANCH PKWY APT 6201
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-7299
Mailing Address - Country:US
Mailing Address - Phone:229-518-8891
Mailing Address - Fax:
Practice Address - Street 1:2300 WOLF RANCH PKWY APT 6201
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-7299
Practice Address - Country:US
Practice Address - Phone:229-518-8891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5931OtherASCP