Provider Demographics
NPI:1871506378
Name:CASTILLO, CLARISSA A (PA)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:A
Last Name:CASTILLO
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 1:1275 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3476
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:619-428-7952
Practice Address - Street 1:4004 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:619-428-7952
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18154364SF0001X
CA18154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FHC18880FOtherMEDI-CAL
Q61727Medicare UPIN
W5740Medicare ID - Type Unspecified