Provider Demographics
NPI:1164495495
Name:KOSKELLA, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:KOSKELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 NW ANDERSON HILL RD
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-6807
Mailing Address - Country:US
Mailing Address - Phone:360-698-6630
Mailing Address - Fax:360-698-7002
Practice Address - Street 1:4409 NW ANDERSON HILL RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6807
Practice Address - Country:US
Practice Address - Phone:360-698-6630
Practice Address - Fax:360-698-7002
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038111207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1115062Medicaid
WA0199376OtherLABOR AND INDUSTRIES
WAP00267733OtherRAILROAD MEDICARE
WA0199376OtherLABOR AND INDUSTRIES
WAP00267733OtherRAILROAD MEDICARE