Provider Demographics
NPI:1063415156
Name:COSTELLO, DANIEL G (PA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:G
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10543 KENAI SPUR HWY
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7812
Mailing Address - Country:US
Mailing Address - Phone:907-395-0463
Mailing Address - Fax:907-395-0483
Practice Address - Street 1:1526 COLE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3410
Practice Address - Country:US
Practice Address - Phone:303-379-9371
Practice Address - Fax:303-423-7004
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0044363A00000X
CO2300363AM0700X
AK135562363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97259365Medicaid
AK1687798Medicaid
COQ37507Medicare UPIN
COQ37507Medicare UPIN