Healthcare Provider Details

I. General information

NPI: 1003374588
Provider Name (Legal Business Name): NICOLE KOSMIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE NEFF RD
BEND OR
97701-6015
US

IV. Provider business mailing address

2500 NE NEFF RD
BEND OR
97701-6015
US

V. Phone/Fax

Practice location:
  • Phone: 888-333-1095
  • Fax:
Mailing address:
  • Phone: 888-333-1095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDO223392
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: