Provider Demographics
NPI:1184982936
Name:VARGHESE, KOSHY (PTA)
Entity type:Individual
Prefix:
First Name:KOSHY
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 W FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-3419
Mailing Address - Country:US
Mailing Address - Phone:813-265-1600
Mailing Address - Fax:
Practice Address - Street 1:518 W FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3419
Practice Address - Country:US
Practice Address - Phone:813-265-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA10657225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant