Provider Demographics
NPI:1730104340
Name:COSTELLO, EDWARD T (PA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:T
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1002 SCHNEIDER DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-4816
Mailing Address - Country:US
Mailing Address - Phone:501-332-7981
Mailing Address - Fax:501-337-9964
Practice Address - Street 1:1002 SCHNEIDER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-4816
Practice Address - Country:US
Practice Address - Phone:501-332-7981
Practice Address - Fax:501-337-9964
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-05-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARPA-251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1730104340Medicare PIN
ARS94370Medicare UPIN