Healthcare Provider Details

I. General information

NPI: 1235967050
Provider Name (Legal Business Name): KENDRICK RUELO DE CASTRO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWER RD NE STE 200
MARIETTA GA
30060-9412
US

IV. Provider business mailing address

1845 PIEDMONT AVE NE APT 522
ATLANTA GA
30324-5170
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1372
  • Fax:
Mailing address:
  • Phone: 404-861-1549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12626
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: