Provider Demographics
NPI:1699170282
Name:KOSTELAC, ANDREA (NP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:KOSTELAC
Suffix:
Gender:F
Credentials:NP
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 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:314 S WELLS ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1098
Practice Address - Country:US
Practice Address - Phone:304-652-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-26
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16754-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810029053Medicaid
OH0113916Medicaid
OHP01469172OtherMEDICARE RAILROAD
OHH398840Medicare PIN
OH0113916Medicaid