Provider Demographics
NPI:1710172135
Name:KODYSH, PATRICIA GAIL (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:GAIL
Last Name:KODYSH
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 1:6195 LUSK BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3715
Mailing Address - Country:US
Mailing Address - Phone:619-977-8220
Mailing Address - Fax:
Practice Address - Street 1:6195 LUSK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3715
Practice Address - Country:US
Practice Address - Phone:619-977-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA608951363LF0000X
CA17488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily