Provider Demographics
NPI:1124268669
Name:COSTELLO, MARTIN (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 PENN ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19602-1096
Mailing Address - Country:US
Mailing Address - Phone:610-375-7740
Mailing Address - Fax:610-898-1149
Practice Address - Street 1:526 PENN ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19602-1096
Practice Address - Country:US
Practice Address - Phone:610-375-7740
Practice Address - Fax:610-898-1149
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001312L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical