Provider Demographics
NPI:1851940571
Name:COSTINE, MICHAEL A
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:COSTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7556 HAMPTON AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-5544
Mailing Address - Country:US
Mailing Address - Phone:617-721-3437
Mailing Address - Fax:
Practice Address - Street 1:5363 BALBOA BLVD STE 445
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2844
Practice Address - Country:US
Practice Address - Phone:818-946-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant