Provider Demographics
NPI:1164894697
Name:CASTELLANOS-PITCOCK, MERCEDES B (PA-C)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:B
Last Name:CASTELLANOS-PITCOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MERCEDES
Other - Middle Name:
Other - Last Name:CASTELLANOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:7855 S EMERSON AVE STE P
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8669
Practice Address - Country:US
Practice Address - Phone:317-781-7343
Practice Address - Fax:317-788-4746
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001908A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009060Medicaid