Provider Demographics
NPI:1972588408
Name:COSTELLO, DAVID M (PA - C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
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 1:1285 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4984
Mailing Address - Country:US
Mailing Address - Phone:407-599-3710
Mailing Address - Fax:407-643-2807
Practice Address - Street 1:1285 ORANGE AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4984
Practice Address - Country:US
Practice Address - Phone:407-599-3710
Practice Address - Fax:407-643-2807
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2227363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290340700Medicaid
FLE5054YMedicare PIN
FL290340700Medicaid