Provider Demographics
NPI:1326130451
Name:CASTOR, TANYA (PA-C)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:CASTOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 ANDERSON AVE
Mailing Address - Street 2:BLDG C
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-7602
Mailing Address - Country:US
Mailing Address - Phone:785-539-3504
Mailing Address - Fax:785-539-8597
Practice Address - Street 1:4201 ANDERSON AVE
Practice Address - Street 2:BLDG C
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-7602
Practice Address - Country:US
Practice Address - Phone:785-539-3504
Practice Address - Fax:785-539-8597
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200405210AMedicaid
KS427042Medicare PIN
KS200405210AMedicaid