Provider Demographics
NPI:1255614145
Name:KOSTENBADER, ANGELA (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:KOSTENBADER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:CHASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:180 GIBBS ROAD
Mailing Address - Street 2:
Mailing Address - City:WISCASSET
Mailing Address - State:ME
Mailing Address - Zip Code:04578
Mailing Address - Country:US
Mailing Address - Phone:207-380-4349
Mailing Address - Fax:
Practice Address - Street 1:35 MEDICAL CENTER PARKWAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-626-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1269363A00000X
ME1269PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant