Provider Demographics
NPI:1194116616
Name:CASTILLO, LORENA A (PA-C)
Entity type:Individual
Prefix:MISS
First Name:LORENA
Middle Name:A
Last Name:CASTILLO
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:404-256-4777
Mailing Address - Fax:404-256-5515
Practice Address - Street 1:1505 NORTHSIDE BLVD STE 4600
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7658
Practice Address - Country:US
Practice Address - Phone:770-205-5292
Practice Address - Fax:404-205-5291
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA7131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003176164DMedicaid
GA003176164EMedicaid
GAG15813BOtherMEDICARE PTAN