Provider Demographics
NPI:1699147827
Name:COSTIN, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:COSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 RUSSELL AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1034
Mailing Address - Country:US
Mailing Address - Phone:317-441-4041
Mailing Address - Fax:
Practice Address - Street 1:2265 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1737
Practice Address - Country:US
Practice Address - Phone:612-645-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist