Provider Demographics
NPI:1316960818
Name:KOSACK, ANDREA DINGMAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:DINGMAN
Last Name:KOSACK
Suffix:
Gender:F
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 1:34 HALF MILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3507
Mailing Address - Country:US
Mailing Address - Phone:203-809-5908
Mailing Address - Fax:
Practice Address - Street 1:20 YORK STREET
Practice Address - Street 2:YNHH NBSCU
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06412
Practice Address - Country:US
Practice Address - Phone:203-688-2320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant