Provider Demographics
NPI:1164499463
Name:KOSIK, SANDRA LEIGH (PA)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LEIGH
Last Name:KOSIK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18465 S WINNIFRED AVE
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-8847
Mailing Address - Country:US
Mailing Address - Phone:503-319-5810
Mailing Address - Fax:
Practice Address - Street 1:200 S HAZEL DELL WAY
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-7829
Practice Address - Country:US
Practice Address - Phone:503-263-9500
Practice Address - Fax:503-263-1383
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136296Medicaid
OR121063Medicare ID - Type Unspecified
ORQ24919Medicare UPIN