Provider Demographics
NPI:1548604408
Name:CASTILLO, MARK A (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:CASTILLO
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 1:1310 SOUTHERN AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-4623
Mailing Address - Country:US
Mailing Address - Phone:202-741-3296
Mailing Address - Fax:
Practice Address - Street 1:1310 SOUTHERN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4623
Practice Address - Country:US
Practice Address - Phone:202-741-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant