Basic Information
| Provider Information | |||||||||
| NPI: | 1316605587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2253 | ||||||||
| Address2: | |||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301020005 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1365C CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047122000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2021 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN288232 | GA | N | Nursing Service Providers | Registered Nurse | 363L00000X | RN288232 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.