Provider Demographics
NPI:1578695581
Name:COSENZA, LINDA (CLS)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:COSENZA
Suffix:
Gender:F
Credentials:CLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 BOVET RD FL 6
Mailing Address - Street 2:ATTN: CD BILLING
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3116
Mailing Address - Country:US
Mailing Address - Phone:701-255-9279
Mailing Address - Fax:701-222-4142
Practice Address - Street 1:4892 SCREECH OWL CREEK RD
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-8073
Practice Address - Country:US
Practice Address - Phone:800-600-3554
Practice Address - Fax:701-222-4142
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACL10911291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB698660Medicaid
CAX16299Medicare UPIN
CAZZZ01277ZMedicare ID - Type Unspecified