Provider Demographics
NPI:1720820657
Name:CASTELLANOS, RAFAEL
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CASTELLANOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 STATE ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2445 STATE ROUTE 30
Practice Address - Street 2:
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986-2502
Practice Address - Country:US
Practice Address - Phone:518-359-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY406090363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health