Basic Information
Provider Information | |||||||||
NPI: | 1609856798 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADAMS | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | COSTELLO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COSTELLO | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | LILLIAN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 17567 WAYSIDE DR | ||||||||
Address2: |   | ||||||||
City: | DUMFRIES | ||||||||
State: | VA | ||||||||
PostalCode: | 220264513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032214776 | ||||||||
FaxNumber: | 7035761414 | ||||||||
Practice Location | |||||||||
Address1: | 14450 SMOKETOWN RD | ||||||||
Address2: |   | ||||||||
City: | WOODBRIDGE | ||||||||
State: | VA | ||||||||
PostalCode: | 221924712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035761419 | ||||||||
FaxNumber: | 7035761414 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0110001270 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.