MEDICARE: MRS. LINDSAY MARIE COSTELLO MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2362	AK

General Provider Information

NPI Number	:	1306090766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LINDSAY MARIE COSTELLO MPT

Provider Business Mailing Address
First Line	:	4001 GEIST RD
Second Line	:	STE 12
City	:	FAIRBANKS
State	:	AK
Zip	:	99709-3569
Country	:	US
Telephone Number	:	907-374-1981
Fax Number	:	907-374-1983

Provider Business Practice Location Address
First Line	:	4001 GEIST RD
Second Line	:	STE 12
City	:	FAIRBANKS
State	:	AK
Zip	:	99709-3569
Country	:	US
Telephone Number	:	907-374-1981
Fax Number	:	907-374-1983

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2008
Last Update Date	:	03/12/2018

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