Provider Demographics
NPI:1427069160
Name:COSTELLO, PAUL C (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:C
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3007
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98114-3007
Mailing Address - Country:US
Mailing Address - Phone:206-788-3616
Mailing Address - Fax:206-652-5216
Practice Address - Street 1:16549 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5308
Practice Address - Country:US
Practice Address - Phone:206-533-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038198207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1010103Medicaid
WA8252157Medicaid
WA152833OtherWORK COMP
WAA002OtherTRICARE