Healthcare Provider Details

I. General information

NPI: 1366734451
Provider Name (Legal Business Name): MEGAN MAY KOSTYAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST INTERVENTIONAL RADIOLOGY, SUITE A PARK PAVILION
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-7237
  • Fax: 215-707-9389
Mailing address:
  • Phone: 215-707-7237
  • Fax: 215-707-9389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052171
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: