Provider Demographics
NPI:1235967050
Name:DE CASTRO, KENDRICK RUELO (PA-C)
Entity type:Individual
Prefix:
First Name:KENDRICK
Middle Name:RUELO
Last Name:DE CASTRO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 PIEDMONT AVE NE APT 522
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5170
Mailing Address - Country:US
Mailing Address - Phone:404-861-1549
Mailing Address - Fax:
Practice Address - Street 1:400 TOWER RD NE STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9412
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA12626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program