Provider Demographics
NPI:1770878779
Name:KOSBERG, PAULA AUGUSTINA
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:AUGUSTINA
Last Name:KOSBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:390 E PARKCENTER BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6662
Practice Address - Country:US
Practice Address - Phone:208-336-8433
Practice Address - Fax:208-336-8441
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1770878779Medicaid
ID1652938Medicare PIN