Provider Demographics
NPI:1760487722
Name:KOSMACH, FREDERICK D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:D
Last Name:KOSMACH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W SHELL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MINONG
Mailing Address - State:WI
Mailing Address - Zip Code:54859-9302
Mailing Address - Country:US
Mailing Address - Phone:715-466-2201
Mailing Address - Fax:715-466-2205
Practice Address - Street 1:600 W SHELL CREEK RD
Practice Address - Street 2:
Practice Address - City:MINONG
Practice Address - State:WI
Practice Address - Zip Code:54859-9302
Practice Address - Country:US
Practice Address - Phone:715-466-2201
Practice Address - Fax:715-466-2205
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI897363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42978900Medicaid
WI42978900Medicaid
WI66020-0013Medicare ID - Type UnspecifiedMEDICARE NUMBER