Healthcare Provider Details

I. General information

NPI: 1235335944
Provider Name (Legal Business Name): JAN M CASTRO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5495 S 500 E STE 120
OGDEN UT
84405-6923
US

IV. Provider business mailing address

5495 S 500 E STE 120
OGDEN UT
84405-6923
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-0174
  • Fax: 801-479-8888
Mailing address:
  • Phone: 801-479-0174
  • Fax: 801-479-8888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number198466-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: