Individual
MR. KEVIN ROBERT COSTELLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0017075
MEDICARE PTAN
—
05
—
30338176
—
NH
Enumeration date
05/09/2006
Last updated
04/16/2012
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