Provider Demographics
NPI:1679396659
Name:KOSTOVICH, NICHOLAS (PTA)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:KOSTOVICH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10683 SW CAM RUN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2351
Mailing Address - Country:US
Mailing Address - Phone:716-903-6636
Mailing Address - Fax:
Practice Address - Street 1:211 S NARCISSUS AVE # MU-1
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-5654
Practice Address - Country:US
Practice Address - Phone:561-790-8256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26020225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant