MEDICARE: WALCES CASTELLY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	000417-P.A.	PR
2	363AM0700X	Medical Physician Assistant	10288	AZ

General Provider Information

NPI Number	:	1568006682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALCES CASTELLY PA

Provider Business Mailing Address
First Line	:	5955 W PEORIA AVE
Second Line	:	PO BOX # 5361
City	:	GLENDALE
State	:	AZ
Zip	:	85302-1204
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5955 W PEORIA AVE
Second Line	:	PO BOX # 5361
City	:	GLENDALE
State	:	AZ
Zip	:	85302-1204
Country	:	US
Telephone Number	:	347-488-2801
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2019
Last Update Date	:	02/10/2026

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