Provider Demographics
NPI:1487439170
Name:KOSTEK, HUBERT (MSPAS)
Entity type:Individual
Prefix:
First Name:HUBERT
Middle Name:
Last Name:KOSTEK
Suffix:
Gender:M
Credentials:MSPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 OVERLAND DR
Mailing Address - Street 2:
Mailing Address - City:LONG POND
Mailing Address - State:PA
Mailing Address - Zip Code:18334-7824
Mailing Address - Country:US
Mailing Address - Phone:570-216-2068
Mailing Address - Fax:
Practice Address - Street 1:206 E BROWN ST
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3006
Practice Address - Country:US
Practice Address - Phone:570-421-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA065128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0965898Medicaid