Healthcare Provider Details

I. General information

NPI: 1548998578
Provider Name (Legal Business Name): NICHOLAS MARK KOSTELEC NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

90 BURTIS AVE
ROCKVILLE CENTRE NY
11570-2902
US

V. Phone/Fax

Practice location:
  • Phone: 646-929-7800
  • Fax:
Mailing address:
  • Phone: 516-510-3286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF432366-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: