Healthcare Provider Details

I. General information

NPI: 1669006839
Provider Name (Legal Business Name): ANDREA VICTORIA CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HOSPITAL BLVD STE 250
ROSWELL GA
30076-4990
US

IV. Provider business mailing address

2436 HAMPTON PARK DR
BUFORD GA
30519-2230
US

V. Phone/Fax

Practice location:
  • Phone: 770-442-1111
  • Fax: 770-740-2990
Mailing address:
  • Phone: 404-775-0533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9850
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: