Healthcare Provider Details

I. General information

NPI: 1033301866
Provider Name (Legal Business Name): RONALD D. KOSANKE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 S. 4TH STREET
GANADO TX
77962-0000
US

IV. Provider business mailing address

204 S. 4TH STREET
GANADO TX
77962-0000
US

V. Phone/Fax

Practice location:
  • Phone: 361-771-3311
  • Fax: 361-771-3081
Mailing address:
  • Phone: 361-771-3311
  • Fax: 361-771-3081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00585
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: