Basic Information
| Provider Information | |||||||||
| NPI: | 1871175646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTAN | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | ALEXANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1574 MEDICAL CENTER PKWY STE 104 | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371293761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152252070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1574 MEDICAL CENTER PKWY STE 104 | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371293761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152252070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2021 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.