Provider Demographics
NPI:1114543055
Name:CASTANEDA, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CASTANEDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 W ROSEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1856
Mailing Address - Country:US
Mailing Address - Phone:847-910-6059
Mailing Address - Fax:
Practice Address - Street 1:1875 DEMPSTER ST STE 110
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1125
Practice Address - Country:US
Practice Address - Phone:847-897-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021107363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily