Healthcare Provider Details

I. General information

NPI: 1336503036
Provider Name (Legal Business Name): VINCENT J COSTELLA PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 W MARKET ST STE 250
GREENSBORO NC
27403-4445
US

IV. Provider business mailing address

3511 W MARKET ST STE 250
GREENSBORO NC
27403-4445
US

V. Phone/Fax

Practice location:
  • Phone: 336-852-3800
  • Fax: 336-852-5725
Mailing address:
  • Phone: 336-852-3800
  • Fax: 336-852-5725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06358
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-06358
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: