Provider Demographics
NPI:1851494942
Name:COSTA, MAXINE (APRN)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:COSTA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WOODLAND STREET
Mailing Address - Street 2:SUITE 31
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-728-1212
Mailing Address - Fax:860-724-5224
Practice Address - Street 1:19 WOODLAND STREET
Practice Address - Street 2:SUITE 31
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105
Practice Address - Country:US
Practice Address - Phone:860-728-1212
Practice Address - Fax:860-724-5224
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000861364SW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004207719Medicaid
890000281Medicare ID - Type Unspecified
CT004207719Medicaid