Provider Demographics
NPI:1669495412
Name:EVANGELISTA, PAUL VINCENT CASTILLO (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL VINCENT
Middle Name:CASTILLO
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13609 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6500
Mailing Address - Country:US
Mailing Address - Phone:917-400-2425
Mailing Address - Fax:718-321-8115
Practice Address - Street 1:13609 38TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6500
Practice Address - Country:US
Practice Address - Phone:917-400-2425
Practice Address - Fax:718-321-8115
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0265291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11625997OtherCAQH