Provider Demographics
NPI:1780668202
Name:KOSLA, ALISA L (NP)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:L
Last Name:KOSLA
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:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-3206
Practice Address - Fax:774-442-4668
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239471363L00000X
MARN239471363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110024813AMedicaid
042472266OtherTRICARE/CHAMPUS
NP9688OtherBLUE SHIELD INDEMNITY
NP4951OtherMEDICARE B
MA702927Medicaid
702927OtherMEDICAID/WELFARE
92122OtherFALLON COMMUNITY HEALTH P
NP9688OtherBLUE CARE ELECT
AA30963OtherHARVARD PILGRIM HEALTHCAR
P56432Medicare UPIN
MANP4951Medicare ID - Type Unspecified