Healthcare Provider Details

I. General information

NPI: 1194116616
Provider Name (Legal Business Name): LORENA A. CASTILLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 NORTHSIDE BLVD STE 4600
CUMMING GA
30041-7658
US

IV. Provider business mailing address

1835 SAVOY DR STE 300
ATLANTA GA
30341-1071
US

V. Phone/Fax

Practice location:
  • Phone: 770-205-5292
  • Fax: 404-205-5291
Mailing address:
  • Phone: 404-256-4777
  • Fax: 404-256-5515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7131
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: