Basic Information
Provider Information | |||||||||
NPI: | 1588066468 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOSTREWA | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ANP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VAIL | ||||||||
OtherFirstName: | JESSICA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ANP-BC | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | ELM AND CARLTON STREETS | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142630001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168452300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | ELM AND CARLTON STREETS RPCI CLINICAL PRACTICE PLAN | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 14263 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168452300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2014 | ||||||||
LastUpdateDate: | 01/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F306893 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | F306893 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 04039149 | 05 | NY |   | MEDICAID |