Provider Demographics
NPI:1699546085
Name:TAKAHASHI, KOTA
Entity type:Individual
Prefix:
First Name:KOTA
Middle Name:
Last Name:TAKAHASHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 S SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5574
Mailing Address - Country:US
Mailing Address - Phone:479-283-6931
Mailing Address - Fax:
Practice Address - Street 1:1005 S SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5574
Practice Address - Country:US
Practice Address - Phone:479-283-6931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program