Basic Information
| Provider Information | |||||||||
| NPI: | 1922069673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 QUAKER LN | ||||||||
| Address2: | STE. 207C | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272623832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368832500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 306 WESTWOOD AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272624341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368856168 | ||||||||
| FaxNumber: | 3368856402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 10/04/2016 | ||||||||
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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 | 363A00000X | 102803 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970016973 | 01 | NC | RR MEDICARE | OTHER |