Provider Demographics
NPI:1003797572
Name:KASTAMA, MICHAEL R
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:KASTAMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 KING GEORGE AVE SW APT 2
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4843
Mailing Address - Country:US
Mailing Address - Phone:253-820-4758
Mailing Address - Fax:
Practice Address - Street 1:421 KING GEORGE AVE SW APT 2
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4843
Practice Address - Country:US
Practice Address - Phone:253-820-4758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant