Provider Demographics
NPI:1780068924
Name:KOSTELECKY, ROCHELL R (PA-C)
Entity type:Individual
Prefix:
First Name:ROCHELL
Middle Name:R
Last Name:KOSTELECKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROCHELL
Other - Middle Name:R
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 5215
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0215
Mailing Address - Country:US
Mailing Address - Phone:253-403-8327
Mailing Address - Fax:
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-8327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60700601363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2071177Medicaid