Provider Demographics
NPI:1003389743
Name:CASTANEDA, TANIA
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:CASTANEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1196 THIRD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-3131
Mailing Address - Country:US
Mailing Address - Phone:619-745-3596
Mailing Address - Fax:
Practice Address - Street 1:1196 THIRD AVE FL 1
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-3103
Practice Address - Country:US
Practice Address - Phone:619-745-3596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5592817175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18518676OtherKAISER PERMANENTE