Provider Demographics
NPI:1912690355
Name:COSTELLO, IAN JOSEPH
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JOSEPH
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 GEIST RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3569
Mailing Address - Country:US
Mailing Address - Phone:907-374-1981
Mailing Address - Fax:907-331-0440
Practice Address - Street 1:4001 GEIST RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3569
Practice Address - Country:US
Practice Address - Phone:907-374-1981
Practice Address - Fax:907-331-0440
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK204821111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor