Basic Information
| Provider Information | |||||||||
| NPI: | 1770214959 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3228 STATE ROUTE 27 STE 2A | ||||||||
| Address2: | |||||||||
| City: | KENDALL PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088241524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322970032 | ||||||||
| FaxNumber: | 7322970558 | ||||||||
| Practice Location | |||||||||
| Address1: | 3228 STATE ROUTE 27 STE 2A | ||||||||
| Address2: | |||||||||
| City: | KENDALL PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088241524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322970032 | ||||||||
| FaxNumber: | 7322970558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA02093300 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.