Provider Demographics
NPI:1336747567
Name:CASTANEDA, JENAI (PA-C)
Entity type:Individual
Prefix:
First Name:JENAI
Middle Name:
Last Name:CASTANEDA
Suffix:
Gender:M
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 1:12490 BUSINESS CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12490 BUSINESS CENTER DR # 100
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5833
Practice Address - Country:US
Practice Address - Phone:605-528-5857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-10
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58587363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant