Provider Demographics
NPI:1477038610
Name:COSTELLO, CHRISTOPHER JULIUS (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JULIUS
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 1:2345 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5419
Mailing Address - Country:US
Mailing Address - Phone:480-893-2345
Mailing Address - Fax:480-926-0495
Practice Address - Street 1:2345 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5419
Practice Address - Country:US
Practice Address - Phone:480-893-2345
Practice Address - Fax:480-926-0495
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine