Provider Demographics
NPI:1154564375
Name:CASTELLANOS, TONYA ROSETTA (IDMT)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:ROSETTA
Last Name:CASTELLANOS
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:ROSETTA
Other - Last Name:CASTELLANOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IDMT
Mailing Address - Street 1:104 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-7700
Mailing Address - Country:US
Mailing Address - Phone:508-250-6336
Mailing Address - Fax:
Practice Address - Street 1:PSC 41
Practice Address - Street 2:UNIT 5210 230
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09464-9998
Practice Address - Country:US
Practice Address - Phone:0163-852-8148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians