Healthcare Provider Details

I. General information

NPI: 1912644592
Provider Name (Legal Business Name): PARSA KOOCHAK KOSARI PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12617 RIDGELINE BLVD BLDG C105
CEDAR PARK TX
78613-1606
US

IV. Provider business mailing address

6801 ELLSWORTH WALK
AUSTIN TX
78724-4525
US

V. Phone/Fax

Practice location:
  • Phone: 512-996-0441
  • Fax:
Mailing address:
  • Phone: 512-740-8191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1360245
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: