Provider Demographics
NPI:1790014660
Name:CASTILLEJA EZERNACK, ATHENA LEE (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:ATHENA
Middle Name:LEE
Last Name:CASTILLEJA EZERNACK
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 BARKSDALE BLVD E
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2125
Mailing Address - Country:US
Mailing Address - Phone:318-456-6165
Mailing Address - Fax:
Practice Address - Street 1:407 BARKSDALE BLVD E
Practice Address - Street 2:
Practice Address - City:BARKSDALE AFB
Practice Address - State:LA
Practice Address - Zip Code:71110-2125
Practice Address - Country:US
Practice Address - Phone:318-456-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians