Provider Demographics
NPI:1164469094
Name:KOSSUTH, THERESE K (PA-C)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:K
Last Name:KOSSUTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7410884
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0884
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:2851 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3314
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL2558363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2916177 00Medicaid
FL2916177 00Medicaid
FLU1300XMedicare PIN