Provider Demographics
NPI:1104845239
Name:COSTANZO, PAUL STEPHEN (PA-C)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:STEPHEN
Last Name:COSTANZO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:SUITE L3
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1040
Practice Address - Country:US
Practice Address - Phone:269-657-1595
Practice Address - Fax:269-657-1534
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003700363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H060020OtherBCBSM
MIH06012057Medicare PIN
MI0H060020OtherBCBSM