Healthcare Provider Details

I. General information

NPI: 1235919903
Provider Name (Legal Business Name): WILLIAM NUNES COSTA LSA, SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 HILLSIDE LAKE TER APT 605
GAITHERSBURG MD
20878-5242
US

IV. Provider business mailing address

903 HILLSIDE LAKE TER APT 605
GAITHERSBURG MD
20878-5242
US

V. Phone/Fax

Practice location:
  • Phone: 443-910-0033
  • Fax:
Mailing address:
  • Phone: 443-910-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA2000032
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: