| NPI | 1841461373 |
|---|---|
| Former Name | KACIE JO COSTELLO |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1295) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00779) |
| Enumeration Date | 2008-03-12 |
| Last Update Date | 2022-07-21 |