Provider Demographics
NPI:1457311334
Name:KOSTER, JEANETTE (NP)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:KOSTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-1813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-8621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024-166756363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010268851Medicaid
VA010268851Medicaid
VA009904C19Medicare PIN
009904C19Medicare PIN