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NPI Code Detail

MEDICARE: JAMES WADE COSTIN

MEDICARE: JAMES WADE COSTIN
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
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1720617202
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAMES WADE COSTIN
Provider Business Mailing Address
First Line : 7153 EDGEWATER PL
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46240-3020
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2901 W OKLAHOMA AVE
Second Line :
City : MILWAUKEE
State : WI
Zip : 53215-4329
Country : US
Telephone Number : 414-649-3323
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/06/2020
Last Update Date : 04/06/2020

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