Provider Demographics
NPI:1942200415
Name:KOSNOSKI, EDWARD MICHAEL
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MICHAEL
Last Name:KOSNOSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10002 SE 240TH ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-4839
Mailing Address - Country:US
Mailing Address - Phone:253-852-2020
Mailing Address - Fax:253-854-2020
Practice Address - Street 1:10002 SE 240TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-4839
Practice Address - Country:US
Practice Address - Phone:253-852-2020
Practice Address - Fax:253-854-2020
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3410152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1021416Medicaid
WA2027381Medicaid
WA1006117Medicaid
WADF8532OtherRAILROAD MEDICARE GROUP
WAKO7760OtherREGENCE
WAP00446408OtherRAILROAD MEDICARE INDIVIDUAL
WA1012250Medicaid
WA0213257OtherLABOR & INDUSTRIES
WA1006117Medicaid
WA5819440003Medicare NSC
WADF8532OtherRAILROAD MEDICARE GROUP
WA1021416Medicaid
WA5819440002Medicare NSC