Provider Demographics
NPI:1710217799
Name:CASTANEDA, MYRIAM E (PA)
Entity Type:Individual
Prefix:
First Name:MYRIAM
Middle Name:E
Last Name:CASTANEDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1257
Mailing Address - Country:US
Mailing Address - Phone:209-394-7913
Mailing Address - Fax:209-394-3660
Practice Address - Street 1:1140 MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1257
Practice Address - Country:US
Practice Address - Phone:209-394-7913
Practice Address - Fax:209-394-3660
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20693OtherLICENSE NUMBER