Provider Demographics
NPI:1972915395
Name:WOODSTOCK FAMILY PRACTICE AND URGENT CARE
Entity type:Organization
Organization Name:WOODSTOCK FAMILY PRACTICE AND URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:ADRIANA
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:770-771-5600
Mailing Address - Street 1:310 GOLD CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5435
Mailing Address - Country:US
Mailing Address - Phone:770-771-5600
Mailing Address - Fax:
Practice Address - Street 1:310 GOLD CREEK TRL
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-5435
Practice Address - Country:US
Practice Address - Phone:770-771-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7131363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty