Provider Demographics
NPI:1386408599
Name:KOSTERMAN, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KOSTERMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PAWLOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2424 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-2410
Mailing Address - Country:US
Mailing Address - Phone:414-768-8055
Mailing Address - Fax:414-768-5720
Practice Address - Street 1:2424 15TH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-2410
Practice Address - Country:US
Practice Address - Phone:414-768-8055
Practice Address - Fax:414-768-5720
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5366-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily