Provider Demographics
NPI:1508344821
Name:CASTANETO, THYSSEN V (FNP-C)
Entity Type:Individual
Prefix:
First Name:THYSSEN
Middle Name:V
Last Name:CASTANETO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 ATHENA PL
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3692
Mailing Address - Country:US
Mailing Address - Phone:310-212-5185
Mailing Address - Fax:
Practice Address - Street 1:25825 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3518
Practice Address - Country:US
Practice Address - Phone:310-517-3150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95009001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95009001Medicaid
CANP95009001OtherMEDICAL