Healthcare Provider Details

I. General information

NPI: 1457645574
Provider Name (Legal Business Name): CANDICE NICOLE CASTRO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24331 EL TORO RD STE 200
LAGUNA WOODS CA
92637-3116
US

IV. Provider business mailing address

16 VIA DESTINO
SAN CLEMENTE CA
92673-7013
US

V. Phone/Fax

Practice location:
  • Phone: 949-767-0800
  • Fax:
Mailing address:
  • Phone: 949-370-4335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA21621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: