Provider Demographics
NPI:1750555173
Name:GOSTOMSKI, KARA (PTA)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:GOSTOMSKI
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2409
Mailing Address - Country:US
Mailing Address - Phone:813-317-8345
Mailing Address - Fax:
Practice Address - Street 1:2132 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2409
Practice Address - Country:US
Practice Address - Phone:813-317-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21166225200000X
CAAT9461225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant