Healthcare Provider Details

I. General information

NPI: 1770129413
Provider Name (Legal Business Name): TABITHA CASTRILLON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

IV. Provider business mailing address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4596
  • Fax: 386-258-3561
Mailing address:
  • Phone: 386-255-4596
  • Fax: 386-258-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9112512
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9112512
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112512
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: