Provider Demographics
NPI:1730774167
Name:KOSSOR, NICK (PT, DPT)
Entity type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:KOSSOR
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HEMPHILL PL STE 130
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4482
Mailing Address - Country:US
Mailing Address - Phone:518-289-5242
Mailing Address - Fax:518-289-5294
Practice Address - Street 1:7 HEMPHILL PL STE 130
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4482
Practice Address - Country:US
Practice Address - Phone:518-289-5242
Practice Address - Fax:518-289-5294
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist