Provider Demographics
NPI:1891584777
Name:DICOSTANZO, ANTHONY (NP)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:DICOSTANZO
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2836 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-5210
Mailing Address - Country:US
Mailing Address - Phone:386-837-0958
Mailing Address - Fax:
Practice Address - Street 1:2836 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-5210
Practice Address - Country:US
Practice Address - Phone:386-951-4538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11039273363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner