Provider Demographics
NPI:1346225265
Name:KOSTAS, GUS ANGELO JR (MS, CRNP)
Entity Type:Individual
Prefix:MR
First Name:GUS
Middle Name:ANGELO
Last Name:KOSTAS
Suffix:JR
Gender:M
Credentials:MS, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 W RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SHARPSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16150-1066
Mailing Address - Country:US
Mailing Address - Phone:724-456-7742
Mailing Address - Fax:
Practice Address - Street 1:1523 W RIDGE AVE
Practice Address - Street 2:
Practice Address - City:SHARPSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16150-1066
Practice Address - Country:US
Practice Address - Phone:724-456-7742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1114946363LF0000X
PATP006397B363LF0000X
OHNP-06532363LF0000X
AZAP1977363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP50506Medicare UPIN
PA063326Medicare ID - Type Unspecified