Provider Demographics
NPI:1669421749
Name:CASTRO, MITCHELL (PA)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:CASTRO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 SOUTH CHEVY CHASE DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205
Practice Address - Country:US
Practice Address - Phone:818-242-8916
Practice Address - Fax:818-241-7708
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAQ61461363A00000X
CAPA15619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ61461Medicare UPIN