Provider Demographics
NPI:1790838399
Name:COSTA, GREGORY (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:COSTA
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 1:620 HALTON RD APT 7101
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3486
Mailing Address - Country:US
Mailing Address - Phone:323-401-5141
Mailing Address - Fax:
Practice Address - Street 1:620 HALTON RD APT 7101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3486
Practice Address - Country:US
Practice Address - Phone:323-401-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016288363A00000X
COPAL2348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25621530Medicaid
CO807566Medicare PIN
COP67549Medicare UPIN
CO25621530Medicaid