Provider Demographics
NPI:1013342468
Name:KOKOULINA, POLINA (PA-C)
Entity Type:Individual
Prefix:
First Name:POLINA
Middle Name:
Last Name:KOKOULINA
Suffix:
Gender:F
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5050
Mailing Address - Fax:208-367-5151
Practice Address - Street 1:900 N LIBERTY ST
Practice Address - Street 2:STE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8704
Practice Address - Country:US
Practice Address - Phone:208-367-5050
Practice Address - Fax:208-367-5151
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1093363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical