Provider Demographics
NPI:1437802287
Name:KOSYAKOVSKY, ALIZA
Entity Type:Individual
Prefix:
First Name:ALIZA
Middle Name:
Last Name:KOSYAKOVSKY
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 1:77 PARK DR APT 20
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ98864363LA2200X
MA2361292363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health