MEDICARE: DR. NICOLE CASTONGUAY MD

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	208000000X	Pediatrics Physician	60001122	WA
2	208000000X	Pediatrics Physician	MD172735	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871770206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE CASTONGUAY MD

Provider Business Mailing Address
First Line	:	2177 NW IRVING ST APT 2
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-3386
Country	:	US
Telephone Number	:	267-847-8209
Fax Number	:

Provider Business Practice Location Address
First Line	:	2177 NW IRVING ST APT 2
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-3386
Country	:	US
Telephone Number	:	267-847-8209
Fax Number	:

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

Provider Enumeration Date	:	01/28/2008
Last Update Date	:	09/11/2019

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