Healthcare Provider Details

I. General information

NPI: 1851940571
Provider Name (Legal Business Name): MICHAEL A COSTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 10/27/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5363 BALBOA BLVD STE 445
ENCINO CA
91316-2844
US

IV. Provider business mailing address

7556 HAMPTON AVE APT 305
WEST HOLLYWOOD CA
90046-5544
US

V. Phone/Fax

Practice location:
  • Phone: 818-946-8424
  • Fax:
Mailing address:
  • Phone: 617-721-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: