Provider Demographics
NPI:1831135318
Name:KOSTER, HERMAN ADRIAAN (PT)
Entity Type:Individual
Prefix:
First Name:HERMAN
Middle Name:ADRIAAN
Last Name:KOSTER
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 1:6724 DESERT CANYON DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7604
Mailing Address - Country:US
Mailing Address - Phone:915-845-3152
Mailing Address - Fax:
Practice Address - Street 1:6358 EDGEMERE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3517
Practice Address - Country:US
Practice Address - Phone:915-562-8525
Practice Address - Fax:915-566-3889
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1054971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX108032703Medicaid
TX83551EMedicare PIN