Provider Demographics
NPI:1457633943
Name:DECASTRO, JODY JAMES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:JAMES
Last Name:DECASTRO
Suffix:
Gender:M
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 1:152 FOOTE AVENUE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701
Mailing Address - Country:US
Mailing Address - Phone:716-664-5290
Mailing Address - Fax:716-664-7630
Practice Address - Street 1:1910 SASSAFRAS ST STE 300
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2716
Practice Address - Country:US
Practice Address - Phone:814-452-7575
Practice Address - Fax:814-452-7574
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015034363AM0700X
PAMA055017363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
12292814OtherCAQH