Provider Demographics
NPI:1902120280
Name:CASTILLO-RODRIGUEZ, RAQUEL
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:CASTILLO-RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 STATE ROUTE 17M
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-4169
Mailing Address - Country:US
Mailing Address - Phone:845-333-7830
Mailing Address - Fax:845-333-7475
Practice Address - Street 1:475 STATE ROUTE 17M
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4169
Practice Address - Country:US
Practice Address - Phone:845-333-7830
Practice Address - Fax:845-333-7475
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03323237Medicaid