Provider Demographics
NPI:1689856809
Name:CASTELLANO, PATRICK FRANCIS (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:FRANCIS
Last Name:CASTELLANO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-985-1399
Mailing Address - Fax:208-955-6501
Practice Address - Street 1:1623 S WELLS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5040
Practice Address - Country:US
Practice Address - Phone:208-985-1399
Practice Address - Fax:208-955-6501
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-224363A00000X
IDTLP-064363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01538158OtherRR MEDICARE
WA319254OtherLABOR & INDUSTRIES
WA2048070Medicaid
WA319254OtherLABOR & INDUSTRIES
WAP01538158OtherRR MEDICARE