Provider Demographics
NPI:1033557897
Name:COSTELLO, KRISTEN C (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:C
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:C
Other - Last Name:BILLMYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1625 N GEORGE MASON DR STE 345
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3690
Mailing Address - Country:US
Mailing Address - Phone:703-717-4400
Mailing Address - Fax:703-717-4401
Practice Address - Street 1:1625 N GEORGE MASON DR STE 345
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3690
Practice Address - Country:US
Practice Address - Phone:703-717-4400
Practice Address - Fax:703-717-4401
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3145-33363A00000X
VA0110005601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033557897Medicaid
WIWI12837045Medicare PIN