Healthcare Provider Details

I. General information

NPI: 1144285149
Provider Name (Legal Business Name): AUGUSTA BLUNDON KOSOWICZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE SUITE 101
CHARLESTON WV
25304-1223
US

IV. Provider business mailing address

3415 MACCORKLE AVE SE
CHARLESTON WV
25304-1334
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-8380
  • Fax: 304-388-8388
Mailing address:
  • Phone: 304-388-8380
  • Fax: 304-388-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number431
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: