Provider Demographics
NPI:1619574209
Name:COSTELLO, MARIA CHRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:CHRISTINE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 CRITTENDEN BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-273-3927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25741363A00000X
NY025741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant