Provider Demographics
NPI:1023594579
Name:KOSTIV, NATHAN M (NNP-BC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:M
Last Name:KOSTIV
Suffix:
Gender:M
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 COYLE AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-537-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009504363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical CareGroup - Single Specialty