Provider Demographics
NPI:1053778910
Name:CASTILLO, JUAN LUIS
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:LUIS
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:LUIS
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1880 LANCASTER DR NE STE 108
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1065
Mailing Address - Country:US
Mailing Address - Phone:971-273-0679
Mailing Address - Fax:503-961-0794
Practice Address - Street 1:1880 LANCASTER DR NE STE 108
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1065
Practice Address - Country:US
Practice Address - Phone:971-273-0679
Practice Address - Fax:503-961-0794
Is Sole Proprietor?:No
Enumeration Date:2016-01-24
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201600993NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500706549Medicaid
OR1228590003Medicare NSC
ORR187160Medicare PIN