=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538042817
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESUS CASTANEDA-GOMEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2025
-----------------------------------------------------
Last Update Date | 07/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11340 W BELL RD STE A-101
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85378-9342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-226-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16663 W SAGUARO LN
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85388-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-285-6775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA-015028
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------