Healthcare Provider Details

I. General information

NPI: 1821188269
Provider Name (Legal Business Name): LETY ELIZABETH COSTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LETY ELIZABETH AMAYA

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 CALIFORNIA AVE
DOS PALOS CA
93620-2300
US

IV. Provider business mailing address

749 EGGLESTON AVE
DOS PALOS CA
93620-9564
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-4842
  • Fax:
Mailing address:
  • Phone: 208-282-0196
  • Fax: 855-202-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME158393
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17517
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number680
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number110879
License Number StateNE
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA187054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: