Provider Demographics
NPI:1750666210
Name:DE COSTER, JAMIE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:MARIE
Last Name:DE COSTER
Suffix:
Gender:
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:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1058
Mailing Address - Country:US
Mailing Address - Phone:760-568-2684
Mailing Address - Fax:760-341-5832
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:HARRY AND DIANE RINKER BLG
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270
Practice Address - Country:US
Practice Address - Phone:760-568-2684
Practice Address - Fax:760-341-5832
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52663363A00000X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical