Provider Demographics
NPI:1992272033
Name:COSTELLO, KENT JAMES (PA)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:JAMES
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:908 NIAGARA FALLS BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-799-1463
Mailing Address - Fax:833-953-2016
Practice Address - Street 1:195 PLEASANT ST UNIT 5
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1081
Practice Address - Country:US
Practice Address - Phone:814-362-5701
Practice Address - Fax:814-362-5702
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2020-10-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY025316363A00000X
PAMA061922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant