Provider Demographics
NPI:1114359858
Name:CASTRO GUSMAN, VARSHA
Entity Type:Individual
Prefix:
First Name:VARSHA
Middle Name:
Last Name:CASTRO GUSMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VARSHA
Other - Middle Name:CASTRO
Other - Last Name:GUSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-975-8259
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-975-8259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05584224Medicaid
LA2341677Medicaid
LA351595YH3UMedicare PIN