Provider Demographics
NPI:1487085676
Name:KOSTISHAK, NICHOLAS MICHAEL JR (PA-C, ATC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:KOSTISHAK
Suffix:JR
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:3469 STEPHEN LN
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3105
Mailing Address - Country:US
Mailing Address - Phone:516-375-6459
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE # 2A05
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:516-375-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0027022255A2300X
NY024450363A00000X
AZ11342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer