Provider Demographics
NPI:1164469094
Name:KOSSUTH, THERESE K (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:K
Last Name:KOSSUTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14690 SPRING HILL DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-8102
Mailing Address - Country:US
Mailing Address - Phone:352-799-0046
Mailing Address - Fax:352-606-2857
Practice Address - Street 1:5350 SPRING HILL DR
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-4562
Practice Address - Country:US
Practice Address - Phone:352-688-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL2558363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2916177 00Medicaid
FL2916177 00Medicaid
FLU1300XMedicare PIN