Provider Demographics
NPI:1326393315
Name:CASTLEBERRY, GORDON LEE (PA)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:LEE
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:566 RUIN CREEK RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2927
Practice Address - Country:US
Practice Address - Phone:919-425-1565
Practice Address - Fax:919-425-0478
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical