Provider Demographics
NPI:1922609114
Name:CASTANEDA CALDERON, JEANNINE (PA-C)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:CASTANEDA CALDERON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:C
Other - Last Name:CALDERON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16966 CAGAN RIDGE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-9656
Mailing Address - Country:US
Mailing Address - Phone:321-843-5851
Mailing Address - Fax:321-843-1673
Practice Address - Street 1:16966 CAGAN RIDGE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-9656
Practice Address - Country:US
Practice Address - Phone:321-843-5851
Practice Address - Fax:321-843-1673
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113816363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113752000Medicaid