Provider Demographics
NPI:1568006682
Name:CASTELLY, WALCES (PA)
Entity Type:Individual
Prefix:
First Name:WALCES
Middle Name:
Last Name:CASTELLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PARK PL APT 2
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-2318
Mailing Address - Country:US
Mailing Address - Phone:347-488-2801
Mailing Address - Fax:
Practice Address - Street 1:6826 W SWEETWATER AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5018
Practice Address - Country:US
Practice Address - Phone:347-488-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR000417-P.A.363AM0700X
AZ10288363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical