Provider Demographics
NPI:1619304680
Name:COSTELLO, ELIZABETH MAREN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MAREN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MAREN
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1990 DOVER RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EPSOM
Mailing Address - State:NH
Mailing Address - Zip Code:03234-4146
Mailing Address - Country:US
Mailing Address - Phone:603-736-6200
Mailing Address - Fax:603-736-6220
Practice Address - Street 1:1990 DOVER RD
Practice Address - Street 2:SUITE 201
Practice Address - City:EPSOM
Practice Address - State:NH
Practice Address - Zip Code:03234-4146
Practice Address - Country:US
Practice Address - Phone:603-736-6200
Practice Address - Fax:603-736-6220
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3091378Medicaid