Provider Demographics
NPI:1669006839
Name:CASTRO, ANDREA VICTORIA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:VICTORIA
Last Name:CASTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 HAMPTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-2230
Mailing Address - Country:US
Mailing Address - Phone:404-775-0533
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL BLVD STE 250
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4990
Practice Address - Country:US
Practice Address - Phone:770-442-1111
Practice Address - Fax:770-740-2990
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA9850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program