Provider Demographics
NPI:1841307386
Name:KOSTAC, GRETA M (APNP)
Entity type:Individual
Prefix:MS
First Name:GRETA
Middle Name:M
Last Name:KOSTAC
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:GRETA
Other - Middle Name:MARIE
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-907-7000
Practice Address - Fax:920-907-7012
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1274-033363L00000X
WI83758-030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41262800Medicaid