Provider Demographics
NPI:1346682291
Name:COSTA HENNIS, PRIYANKA (MD)
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:COSTA HENNIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 E BELL RD STE 106
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2158
Mailing Address - Country:US
Mailing Address - Phone:602-443-1085
Mailing Address - Fax:602-443-1086
Practice Address - Street 1:3811 E BELL RD STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2158
Practice Address - Country:US
Practice Address - Phone:602-443-1085
Practice Address - Fax:602-443-1086
Is Sole Proprietor?:No
Enumeration Date:2013-07-20
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62955207Q00000X
OH35136107208M00000X
NC2016-01798208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1346682291Medicaid
SCNC2881Medicaid
NCNCU513AMedicare PIN