Provider Demographics
NPI:1932886603
Name:KOSTAS, GREGORY M (LPN)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:M
Last Name:KOSTAS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:MR
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:70 HERRING POND RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-1913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 HERRING POND RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-1913
Practice Address - Country:US
Practice Address - Phone:781-983-7681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN86528164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse