Provider Demographics
NPI:1427132018
Name:COSSARO, KIMBERLY ANN
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:COSSARO
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 1:100 CONNETQUOT AVE
Mailing Address - Street 2:APARTMENT 23
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1400
Mailing Address - Country:US
Mailing Address - Phone:631-979-0909
Mailing Address - Fax:631-979-0455
Practice Address - Street 1:327 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2905
Practice Address - Country:US
Practice Address - Phone:631-979-0909
Practice Address - Fax:631-979-0455
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009460363AS0400X, 363AM0700X, 363A00000X
NJMP00119600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant