Provider Demographics
NPI:1407803588
Name:KOSKI, KYLE L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:L
Last Name:KOSKI
Suffix:
Gender:M
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 1:165 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2807
Mailing Address - Country:US
Mailing Address - Phone:520-458-5539
Mailing Address - Fax:520-458-5584
Practice Address - Street 1:11034 N 23RD DR # 105B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4743
Practice Address - Country:US
Practice Address - Phone:602-639-0189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA1865293363AM0700X
AZ3392363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical