Provider Demographics
NPI:1124555107
Name:COSTA, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:COSTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BEAVER POND CT
Mailing Address - Street 2:
Mailing Address - City:STONY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10980-3518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 BEAVER POND CT
Practice Address - Street 2:
Practice Address - City:STONY POINT
Practice Address - State:NY
Practice Address - Zip Code:10980-3518
Practice Address - Country:US
Practice Address - Phone:845-429-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist