Provider Demographics
NPI:1477825651
Name:COSTERISAN, ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:COSTERISAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 MATHERS RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7064
Mailing Address - Country:US
Mailing Address - Phone:217-789-3600
Mailing Address - Fax:
Practice Address - Street 1:2801 MATHERS RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7064
Practice Address - Country:US
Practice Address - Phone:217-789-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9106409363A00000X
IL085004969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant