Provider Demographics
NPI:1720288731
Name:KOSTER, MARY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KOSTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:G
Other - Last Name:TEFFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:200 W DOUGLAS AVE
Mailing Address - Street 2:STE 1040
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3013
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:4515 E CENTRAL AVE
Practice Address - Street 2:STE A
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3915
Practice Address - Country:US
Practice Address - Phone:316-260-6869
Practice Address - Fax:316-260-6872
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-01050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist