Provider Demographics
NPI:1235429119
Name:COSTELLO, CHERYL L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:L
Last Name:COSTELLO
Suffix:
Gender:F
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 1:1317 WOLF ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2934
Mailing Address - Country:US
Mailing Address - Phone:215-755-5449
Mailing Address - Fax:215-755-0010
Practice Address - Street 1:1317 WOLF ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2934
Practice Address - Country:US
Practice Address - Phone:215-755-5449
Practice Address - Fax:215-755-0010
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA000966L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA334576Medicare PIN