Provider Demographics
NPI:1962568402
Name:KOESTER, THERESA MICHELE (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MICHELE
Last Name:KOESTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 WYMAN PARK DR
Mailing Address - Street 2:JHCP BUSINESS OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2803
Mailing Address - Country:US
Mailing Address - Phone:410-338-3500
Mailing Address - Fax:
Practice Address - Street 1:3301 NEW MEXICO AVE NW, SUITE 206
Practice Address - Street 2:JHCP SURGERY FOXHALL
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-3622
Practice Address - Country:US
Practice Address - Phone:202-895-1440
Practice Address - Fax:202-895-1448
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030436363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
405951OtherMEDICARE GROUP PTAN
521467441OtherJHCP TAX ID
022430F51Medicare PIN