Healthcare Provider Details

I. General information

NPI: 1740910413
Provider Name (Legal Business Name): JOSHUA KOTNER MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2199 N MERRIT CRK LOOP
COEUR D ALENE ID
83814-4949
US

IV. Provider business mailing address

1070 WALLEN RD
MOSCOW ID
83843-8458
US

V. Phone/Fax

Practice location:
  • Phone: 619-947-0228
  • Fax:
Mailing address:
  • Phone: 619-947-0228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: