Provider Demographics
NPI:1588066468
Name:KOSTREWA, JESSICA MARIE (ANP-BC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KOSTREWA
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:VAIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP-BC
Mailing Address - Street 1:ELM AND CARLTON STREETS
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14263-0001
Mailing Address - Country:US
Mailing Address - Phone:716-845-2300
Mailing Address - Fax:
Practice Address - Street 1:ELM AND CARLTON STREETS RPCI CLINICAL PRACTICE PLAN
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306893363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04039149Medicaid