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General NPI Number Information
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NPI Number | 1366218414
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Entity Type | Organization
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Legal Business Name | COSTA CLINIC PLLC
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Dates
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Enumeration Date | 11/29/2023
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Last Update Date | 12/14/2023
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Provider Practice Location Address
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Address Line | 3811 E BELL RD STE 106
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City | PHOENIX
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State | AZ
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Zip | 85032-2158
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Country | US
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Telephone | 602-443-1085
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Fax | 602-443-1086
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Provider Business Mailing Address
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Address Line | 1628 E SOUTHERN AVE STE 9803
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City | TEMPE
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State | AZ
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Zip | 85282-5782
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | PRIYANKA COSTA HENNIS
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Credential | MD
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Telephone | 312-625-0574
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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