Healthcare Provider Details

I. General information

NPI: 1851966238
Provider Name (Legal Business Name): SHELBY ANN COSTA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

IV. Provider business mailing address

1400 S ORANGE AVE
ORLANDO FL
32806-2134
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-1893
  • Fax: 321-841-1296
Mailing address:
  • Phone: 321-841-1893
  • Fax: 321-841-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9114837
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: