Provider Demographics
NPI:1437176542
Name:COSTLOW, ANNAMARIE C (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNAMARIE
Middle Name:C
Last Name:COSTLOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNAMARIE
Other - Middle Name:
Other - Last Name:CHYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:104 FOREST GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:PORT MATILDA
Mailing Address - State:PA
Mailing Address - Zip Code:16870-7124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 E PARK AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-6701
Practice Address - Country:US
Practice Address - Phone:814-234-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
018851C95Medicare ID - Type Unspecified
Q13951Medicare UPIN