Provider Demographics
NPI:1760989859
Name:COSTELLO, ERICA LEIGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:LEIGH
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:LEIGH
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5840 E 2ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4363
Mailing Address - Country:US
Mailing Address - Phone:307-315-6133
Mailing Address - Fax:
Practice Address - Street 1:5840 E 2ND ST STE 200
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4363
Practice Address - Country:US
Practice Address - Phone:307-316-6133
Practice Address - Fax:307-315-6134
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA853363AM0700X
CA55430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant