Healthcare Provider Details

I. General information

NPI: 1558765982
Provider Name (Legal Business Name): MIRIAM KOSMOSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STATE ST STE 200
UTICA NY
13502-4258
US

IV. Provider business mailing address

328 PUTNAM ST
WATERVILLE NY
13480-1213
US

V. Phone/Fax

Practice location:
  • Phone: 315-733-7598
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005873
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA057215
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036063
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: