Provider Demographics
NPI:1679576698
Name:KOSTREWA, JAMES H (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:H
Last Name:KOSTREWA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 N 19TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7967
Mailing Address - Country:US
Mailing Address - Phone:602-249-9129
Mailing Address - Fax:602-249-4115
Practice Address - Street 1:7540 N 19TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021
Practice Address - Country:US
Practice Address - Phone:602-249-9129
Practice Address - Fax:602-249-4115
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11394042OtherCAQH
AZ717150Medicaid