Provider Demographics
NPI:1396833257
Name:COSTELLO, BRIAN JOHN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JOHN
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31396
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-8396
Mailing Address - Country:US
Mailing Address - Phone:925-939-8585
Mailing Address - Fax:
Practice Address - Street 1:2405 SHADELANDS DR STE 300
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-5906
Practice Address - Country:US
Practice Address - Phone:925-939-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15532363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA169460Medicare PIN