Healthcare Provider Details

I. General information

NPI: 1427069160
Provider Name (Legal Business Name): PAUL C COSTELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16549 AURORA AVE N
SHORELINE WA
98133-5308
US

IV. Provider business mailing address

PO BOX 3007
SEATTLE WA
98114-3007
US

V. Phone/Fax

Practice location:
  • Phone: 206-533-2600
  • Fax:
Mailing address:
  • Phone: 206-788-3616
  • Fax: 206-652-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00038198
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: