Provider Demographics
NPI:1902300676
Name:CASTRO, MILDRED ALEXANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:ALEXANDRA
Last Name:CASTRO
Suffix:
Gender:F
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 1:15689 SOUTHERN BLVD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE GROVES
Mailing Address - State:FL
Mailing Address - Zip Code:33470-9229
Mailing Address - Country:US
Mailing Address - Phone:561-614-1116
Mailing Address - Fax:
Practice Address - Street 1:15689 SOUTHERN BLVD UNIT 101
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE GROVES
Practice Address - State:FL
Practice Address - Zip Code:33470-9229
Practice Address - Country:US
Practice Address - Phone:561-614-1116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639231640Medicaid