Healthcare Provider Details

I. General information

NPI: 1871506378
Provider Name (Legal Business Name): CLARISSA A CASTILLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 BEYER BLVD
SAN YSIDRO CA
92173
US

IV. Provider business mailing address

1275 30TH ST
SAN DIEGO CA
92154-3476
US

V. Phone/Fax

Practice location:
  • Phone: 619-662-4100
  • Fax: 619-428-7952
Mailing address:
  • Phone: 619-662-4100
  • Fax: 619-428-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberPA18154
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number18154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: