Provider Demographics
NPI:1467430918
Name:KOSTELAC, MICHELLE RENEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:RENEE
Last Name:KOSTELAC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:LAMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4760 UNION DEPOSIT ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-3729
Mailing Address - Country:US
Mailing Address - Phone:717-545-9811
Mailing Address - Fax:717-545-9979
Practice Address - Street 1:4760 UNION DEPOSIT ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-3729
Practice Address - Country:US
Practice Address - Phone:717-545-9811
Practice Address - Fax:717-545-9979
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053165363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ01417Medicare UPIN
PA074744LNRMedicare PIN