Provider Demographics
NPI:1083198956
Name:CROSSROADS PEDIATRICS PLLC
Entity Type:Organization
Organization Name:CROSSROADS PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTANEDA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:432-699-2378
Mailing Address - Street 1:3401 GREENBRIAR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-4653
Mailing Address - Country:US
Mailing Address - Phone:432-699-2378
Mailing Address - Fax:432-699-2394
Practice Address - Street 1:3401 GREENBRIAR STE 400
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-4653
Practice Address - Country:US
Practice Address - Phone:432-699-2378
Practice Address - Fax:432-699-2394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-18
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352429002Medicaid