Provider Demographics
NPI:1558831685
Name:COSTA, PATRICIA LYNETT
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNETT
Last Name:COSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 WALLASEY WAY
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CA
Mailing Address - Zip Code:95368-9246
Mailing Address - Country:US
Mailing Address - Phone:209-604-3728
Mailing Address - Fax:
Practice Address - Street 1:800 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-525-6247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-02
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty