Provider Demographics
NPI:1871397075
Name:KOSTELAC, MATTHEW NICKOLAS
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:NICKOLAS
Last Name:KOSTELAC
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 JUSTIN DRIVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17821
Mailing Address - Country:US
Mailing Address - Phone:570-271-6164
Mailing Address - Fax:570-271-6141
Practice Address - Street 1:35 JUSTIN DRIVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821
Practice Address - Country:US
Practice Address - Phone:570-271-6164
Practice Address - Fax:570-271-6141
Is Sole Proprietor?:No
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program