Healthcare Provider Details

I. General information

NPI: 1417103128
Provider Name (Legal Business Name): GARY COSTANZO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELLIOT WAY EMERGENCY ROOM
MANCHESTER NH
03103-3502
US

IV. Provider business mailing address

250 PLEASANT STREET EMERGENCY DEPT
CONCORD NH
03301-2598
US

V. Phone/Fax

Practice location:
  • Phone: 603-663-2830
  • Fax: 603-663-1849
Mailing address:
  • Phone: 603-227-7000
  • Fax: 603-230-7218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0686
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: