Provider Demographics
NPI:1073632725
Name:KOSIS, WADE TYLER (DC)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:TYLER
Last Name:KOSIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 MERCHANT ST
Mailing Address - Street 2:
Mailing Address - City:AMBRIDGE
Mailing Address - State:PA
Mailing Address - Zip Code:15003-2257
Mailing Address - Country:US
Mailing Address - Phone:724-266-2155
Mailing Address - Fax:
Practice Address - Street 1:1405 MERCHANT ST
Practice Address - Street 2:
Practice Address - City:AMBRIDGE
Practice Address - State:PA
Practice Address - Zip Code:15003-2257
Practice Address - Country:US
Practice Address - Phone:724-266-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002565L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA456566Medicare ID - Type Unspecified