Basic Information
| Provider Information | |||||||||
| NPI: | 1063415156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10543 KENAI SPUR HWY | ||||||||
| Address2: | |||||||||
| City: | KENAI | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996117812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073950463 | ||||||||
| FaxNumber: | 9073950483 | ||||||||
| Practice Location | |||||||||
| Address1: | 1526 COLE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033799371 | ||||||||
| FaxNumber: | 3034237004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2004-0044 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 2300 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 135562 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 97259365 | 05 | CO | MEDICAID | 1687798 | 05 | AK | MEDICAID |