Provider Demographics
NPI:1174568737
Name:COSTON, CAROL L (PA-C)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:COSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2028
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003259363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA127398OtherL&I
WA8383234Medicaid
WAS27262Medicare UPIN
WA127398OtherL&I