Provider Demographics
NPI:1760974513
Name:COSTA, ANTHONY JAMES (ATC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JAMES
Last Name:COSTA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 E MAIN ST STE B5
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2848
Mailing Address - Country:US
Mailing Address - Phone:631-724-3150
Mailing Address - Fax:631-724-3117
Practice Address - Street 1:267 E MAIN ST STE B5
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2848
Practice Address - Country:US
Practice Address - Phone:631-724-3150
Practice Address - Fax:631-724-3117
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer