Provider Demographics
NPI:1144788399
Name:KOSHY, TARA MATHEW
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MATHEW
Last Name:KOSHY
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 1:3326 CHAPELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-4004
Mailing Address - Country:US
Mailing Address - Phone:214-929-7325
Mailing Address - Fax:
Practice Address - Street 1:3326 CHAPELWOOD DR
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4004
Practice Address - Country:US
Practice Address - Phone:214-929-7325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140911363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP140911Medicaid