Basic Information
| Provider Information | |||||||||
| NPI: | 1417103128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTANZO | ||||||||
| FirstName: | GARY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 PLEASANT STREET | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033012598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032277000 | ||||||||
| FaxNumber: | 6032307218 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ELLIOT WAY | ||||||||
| Address2: | EMERGENCY ROOM | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031033502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036632830 | ||||||||
| FaxNumber: | 6036631849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0686 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.