Provider Demographics
NPI:1285101279
Name:KOSTKA, ADAM ROSS
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:ROSS
Last Name:KOSTKA
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 1:3821 HEMLOCK RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3591
Mailing Address - Country:US
Mailing Address - Phone:724-813-5756
Mailing Address - Fax:
Practice Address - Street 1:3821 HEMLOCK RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3591
Practice Address - Country:US
Practice Address - Phone:724-813-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-27
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant