Provider Demographics
NPI:1023672763
Name:CASPILLO, KAELYN CORINNE (PA-C)
Entity type:Individual
Prefix:
First Name:KAELYN
Middle Name:CORINNE
Last Name:CASPILLO
Suffix:
Gender:F
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 1:3273 CLAREMONT WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3328
Mailing Address - Country:US
Mailing Address - Phone:707-254-7117
Mailing Address - Fax:707-265-6435
Practice Address - Street 1:3273 CLAREMONT WAY STE 100
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3328
Practice Address - Country:US
Practice Address - Phone:707-603-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA56914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0102820Medicaid