Provider Demographics
NPI:1073606810
Name:KOTARA, KAREN S (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:S
Last Name:KOTARA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-0761
Mailing Address - Country:US
Mailing Address - Phone:817-565-8904
Mailing Address - Fax:877-515-5209
Practice Address - Street 1:6100 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3703
Practice Address - Country:US
Practice Address - Phone:817-237-3321
Practice Address - Fax:817-237-7970
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J3640Medicare PIN
TXQ08554Medicare UPIN
TX8B4171Medicare PIN
TXTXB125127Medicare PIN