Provider Demographics
NPI:1619587987
Name:COSTELLO, MARK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
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 1:156 CAROLINE ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-3435
Mailing Address - Country:US
Mailing Address - Phone:518-522-0810
Mailing Address - Fax:
Practice Address - Street 1:211 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1090
Practice Address - Country:US
Practice Address - Phone:518-587-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty