Provider Demographics
NPI:1578597100
Name:COSTNER, KENNETH W
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:COSTNER
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 1:785 5TH AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-9206
Practice Address - Country:US
Practice Address - Phone:717-261-0929
Practice Address - Fax:717-261-0902
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV69312363L00000X
PASP013788363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102982740Medicaid
MDP85136Medicare UPIN