Provider Demographics
NPI:1386289874
Name:KOSTA, IRA
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:
Last Name:KOSTA
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 1:17 WORNOM FARM RD
Mailing Address - Street 2:
Mailing Address - City:POQUOSON
Mailing Address - State:VA
Mailing Address - Zip Code:23662-1044
Mailing Address - Country:US
Mailing Address - Phone:646-287-7951
Mailing Address - Fax:
Practice Address - Street 1:17 WORNOM FARM RD
Practice Address - Street 2:
Practice Address - City:POQUOSON
Practice Address - State:VA
Practice Address - Zip Code:23662-1044
Practice Address - Country:US
Practice Address - Phone:646-287-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-08
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178863363L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner