Provider Demographics
NPI:1861441545
Name:COSTELLO, KEVIN ROBERT (PA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ROBERT
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 OLD STREET RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1265
Mailing Address - Country:US
Mailing Address - Phone:603-924-2144
Mailing Address - Fax:
Practice Address - Street 1:458 OLD STREET RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1265
Practice Address - Country:US
Practice Address - Phone:603-924-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30338176Medicaid
0017075OtherMEDICARE PTAN