Provider Demographics
NPI:1538739693
Name:COSTELLO, MATTHEW D
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:D
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 W WESTERN RESERVE RD UNIT 9C
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-4500
Mailing Address - Country:US
Mailing Address - Phone:330-550-5814
Mailing Address - Fax:
Practice Address - Street 1:612 JILLIAN FRANCES CIR
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-1566
Practice Address - Country:US
Practice Address - Phone:330-550-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.418095163W00000X
390200000X
OHAPRN.CRNA.0020479367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program