Provider Demographics
NPI:1902826084
Name:CASTOR, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CASTOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 W 86TH ST
Mailing Address - Street 2:SUITE 152
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2103
Mailing Address - Country:US
Mailing Address - Phone:317-771-1140
Mailing Address - Fax:317-780-5532
Practice Address - Street 1:1427 W 86TH ST
Practice Address - Street 2:SUITE 152
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2103
Practice Address - Country:US
Practice Address - Phone:317-771-1140
Practice Address - Fax:317-780-5532
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001627A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN214460DMedicare PIN
INQ03506Medicare UPIN
IN214180GMedicare PIN