Provider Demographics
NPI:1154860013
Name:KOFAS, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KOFAS
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:SOUTH 7650 EAST, 1010
Mailing Address - Street 2:
Mailing Address - City:CROW AGENCY
Mailing Address - State:MT
Mailing Address - Zip Code:59022
Mailing Address - Country:US
Mailing Address - Phone:406-638-3442
Mailing Address - Fax:
Practice Address - Street 1:SOUTH 7650 EAST 1010
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022
Practice Address - Country:US
Practice Address - Phone:406-638-3442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-52903133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered