Provider Demographics
NPI:1548764814
Name:COSTAS, FERNANDO
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:COSTAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 43002
Mailing Address - Street 2:SUITE 515
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-3002
Mailing Address - Country:US
Mailing Address - Phone:787-508-6919
Mailing Address - Fax:
Practice Address - Street 1:CALLE BARCELO
Practice Address - Street 2:#6
Practice Address - City:JAYUYA
Practice Address - State:PR
Practice Address - Zip Code:00664-9998
Practice Address - Country:US
Practice Address - Phone:787-276-8123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist