Provider Demographics
NPI:1457790511
Name:KOSTAL, TRAVIS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:KOSTAL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N 20TH ST
Mailing Address - Street 2:
Mailing Address - City:BEATRICE
Mailing Address - State:NE
Mailing Address - Zip Code:68310-2618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 N 20TH ST
Practice Address - Street 2:
Practice Address - City:BEATRICE
Practice Address - State:NE
Practice Address - Zip Code:68310-2618
Practice Address - Country:US
Practice Address - Phone:402-239-3244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3780049392Medicare PIN