Healthcare Provider Details

I. General information

NPI: 1386289874
Provider Name (Legal Business Name): IRA KOSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 GLEN ELLYN RD APT 104
BLOOMINGDALE IL
60108-1846
US

IV. Provider business mailing address

212 GLEN ELLYN RD APT 104
BLOOMINGDALE IL
60108-1846
US

V. Phone/Fax

Practice location:
  • Phone: 646-287-7951
  • Fax:
Mailing address:
  • Phone: 646-287-7951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024178863
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024178863
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: