MEDICARE: VANESSA CASTRO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	12029	GA

General Provider Information

NPI Number	:	1770215287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA CASTRO

Provider Business Mailing Address
First Line	:	2615 E WEST CONNECTOR STE 106
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-6854
Country	:	US
Telephone Number	:	770-941-0010
Fax Number	:	770-941-0145

Provider Business Practice Location Address
First Line	:	2615 E WEST CONNECTOR STE 106
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-6854
Country	:	US
Telephone Number	:	770-941-0010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2022
Last Update Date	:	01/03/2024

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Directions to “ VANESSA CASTRO ” Practice Location

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