MEDICARE: MR. ANDREW COSTERISAN PA-C

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	363A00000X	Physician Assistant	PA 9106409	FL
2	363A00000X	Physician Assistant	50.008187RX	OH
3	363A00000X	Physician Assistant	085004969	IL

General Provider Information

NPI Number	:	1477825651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREW COSTERISAN PA-C

Provider Business Mailing Address
First Line	:	2801 MATHERS RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711-7064
Country	:	US
Telephone Number	:	217-789-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 E ALEX BELL RD STE 190
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45459-2752
Country	:	US
Telephone Number	:	937-425-4030
Fax Number	:

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

Provider Enumeration Date	:	02/02/2012
Last Update Date	:	10/01/2025

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