Provider Demographics
NPI:1508004813
Name:COSTELLO, JOSEPH T (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:T
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIRCLE
Mailing Address - Street 2:EVANS ARMY COMMUNITY HOSPITAL
Mailing Address - City:FT. CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913
Mailing Address - Country:US
Mailing Address - Phone:573-999-5952
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIRCLE
Practice Address - Street 2:EVANS ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:573-999-5952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1086039363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYVAD000Medicare UPIN