Provider Demographics
NPI:1114652765
Name:CASTANAGA, MARK DOMINIC (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOMINIC
Last Name:CASTANAGA
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9722 GIFTHOUSE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-4866
Mailing Address - Country:US
Mailing Address - Phone:580-917-1393
Mailing Address - Fax:
Practice Address - Street 1:8116 LAS VEGAS BLVD S
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-1015
Practice Address - Country:US
Practice Address - Phone:702-407-7063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV851962363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner