Provider Demographics
NPI:1841461373
Name:MOODY, KACIE JO COSTELLO (PA)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:JO COSTELLO
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:JO
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 602148
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2148
Mailing Address - Country:US
Mailing Address - Phone:704-667-3380
Mailing Address - Fax:704-667-3381
Practice Address - Street 1:704 GOLD HILL RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8906
Practice Address - Country:US
Practice Address - Phone:704-667-3380
Practice Address - Fax:704-667-3381
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00779363A00000X, 363A00000X
SC1295363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0640PAMedicaid
NC1841461373Medicaid
NCNCN577CMedicare PIN
NCNCN5770386Medicare PIN
NCNCN577DMedicare PIN
NCNCN577BMedicare PIN
SCAA29765042Medicare PIN
SC0640PAMedicaid
NC1841461373Medicaid
NCNCN577EMedicare PIN
SCSC42561909Medicare PIN
SCSC42561909Medicare PIN