Provider Demographics
NPI:1356712053
Name:CASTRO BEGAZO HERTWIG, MARIELLA KATHERINE (PA-C)
Entity type:Individual
Prefix:
First Name:MARIELLA
Middle Name:KATHERINE
Last Name:CASTRO BEGAZO HERTWIG
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIELLA
Other - Middle Name:KATHERINE
Other - Last Name:CASTRO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:199 SCOTT ST FL 8
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-2208
Mailing Address - Country:US
Mailing Address - Phone:917-261-4414
Mailing Address - Fax:
Practice Address - Street 1:199 SCOTT ST FL 8
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14204-2208
Practice Address - Country:US
Practice Address - Phone:917-261-4414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13204363A00000X
IL085007456363A00000X
NY019227363A00000X
CAPA58339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant