Basic Information
| Provider Information | |||||||||
| NPI: | 1265875546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCOSTIC | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265061200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6813423463 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 WAYLAND SMITH DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | UNIONTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7244378200 | ||||||||
| FaxNumber: | 7244376673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP012852 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 97970 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | SP012852 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.