Provider Demographics
NPI:1922069673
Name:COSTELLO, RICHARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:COSTELLO
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 1:624 QUAKER LN
Mailing Address - Street 2:STE. 207C
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-3832
Mailing Address - Country:US
Mailing Address - Phone:336-883-2500
Mailing Address - Fax:
Practice Address - Street 1:306 WESTWOOD AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4341
Practice Address - Country:US
Practice Address - Phone:336-885-6168
Practice Address - Fax:336-885-6402
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC970016973OtherRR MEDICARE
NC2752420MMedicare PIN
NC970016973OtherRR MEDICARE
NCR95750Medicare UPIN
NC2752420NMedicare PIN