Provider Demographics
NPI:1336327394
Name:CASTRO, IVAN ENRIQUE (EMT-B, HS2)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:ENRIQUE
Last Name:CASTRO
Suffix:
Gender:M
Credentials:EMT-B, HS2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1753
Mailing Address - Country:US
Mailing Address - Phone:562-922-5135
Mailing Address - Fax:
Practice Address - Street 1:300 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1753
Practice Address - Country:US
Practice Address - Phone:562-922-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2017-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1688832146N00000X
MN941375146N00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic