Provider Demographics
NPI:1326596396
Name:KOSTKA, CONSTANTINA (PA)
Entity Type:Individual
Prefix:
First Name:CONSTANTINA
Middle Name:
Last Name:KOSTKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 COMMONWEALTH AVE
Mailing Address - Street 2:APT. #16
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5038
Mailing Address - Country:US
Mailing Address - Phone:617-312-5056
Mailing Address - Fax:
Practice Address - Street 1:1560 COMMONWEALTH AVE
Practice Address - Street 2:APT. #16
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-5038
Practice Address - Country:US
Practice Address - Phone:617-312-5056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS71060502363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical