Provider Demographics
NPI:1760482632
Name:COSTELLO, GENEVIEVE (PA)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4306 ALTON RD FL 2D
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2840
Mailing Address - Country:US
Mailing Address - Phone:305-674-2397
Mailing Address - Fax:305-674-2863
Practice Address - Street 1:4306 ALTON RD FL 2D
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2840
Practice Address - Country:US
Practice Address - Phone:305-674-2397
Practice Address - Fax:305-674-2863
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2010-02-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9104431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant