Provider Demographics
NPI:1821188269
Name:COSTA, LETY ELIZABETH (MD)
Entity Type:Individual
Prefix:MRS
First Name:LETY
Middle Name:ELIZABETH
Last Name:COSTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LETY
Other - Middle Name:ELIZABETH
Other - Last Name:AMAYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:749 EGGLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:DOS PALOS
Mailing Address - State:CA
Mailing Address - Zip Code:93620-9564
Mailing Address - Country:US
Mailing Address - Phone:208-282-0196
Mailing Address - Fax:855-202-9336
Practice Address - Street 1:7000 SW 62ND AVE STE 401
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4721
Practice Address - Country:US
Practice Address - Phone:308-529-8704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17517363A00000X
NE680363A00000X
NE110879363LF0000X
FLME158393207Q00000X
CA8159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P72916Medicare UPIN
NE098738003Medicare PIN