Provider Demographics
NPI:1215014485
Name:COSTA, KATHERINE ELIZABETH (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:COSTA
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14780 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4799
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:
Practice Address - Street 1:14780 W MOUNTAIN VIEW BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4799
Practice Address - Country:US
Practice Address - Phone:623-374-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862053207RP1001X
AZAP3211363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00143146OtherMEDICARE UNITEDHEALTHCARE
MS05132705Medicaid
MSQ16309Medicare UPIN
MSP00143146OtherMEDICARE UNITEDHEALTHCARE
AZZ128798Medicare PIN
MS05132705Medicaid