Provider Demographics
NPI:1588007249
Name:CASTILLO, MARTIN DANIEL (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:DANIEL
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 122108
Mailing Address - Street 2:DEPT 2108
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2108
Mailing Address - Country:US
Mailing Address - Phone:337-494-2919
Mailing Address - Fax:337-494-3069
Practice Address - Street 1:1717 OAK PARK BLVD
Practice Address - Street 2:3RD FL
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8991
Practice Address - Country:US
Practice Address - Phone:337-475-8100
Practice Address - Fax:337-475-8510
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2014-06-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAAP07248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2336355Medicaid