Provider Demographics
NPI:1619266954
Name:COSTANZA, CLINT M (,PA)
Entity Type:Individual
Prefix:MR
First Name:CLINT
Middle Name:M
Last Name:COSTANZA
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 1:9001 SUMMA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3726
Mailing Address - Country:US
Mailing Address - Phone:225-761-5200
Mailing Address - Fax:225-761-5702
Practice Address - Street 1:9001 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5200
Practice Address - Fax:225-761-5702
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200436363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07908012Medicaid
LA2141252Medicaid
MS07908012Medicaid