Provider Demographics
NPI:1871770206
Name:CASTONGUAY, NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:CASTONGUAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2177 NW IRVING ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3386
Mailing Address - Country:US
Mailing Address - Phone:267-847-8209
Mailing Address - Fax:
Practice Address - Street 1:2177 NW IRVING ST APT 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3386
Practice Address - Country:US
Practice Address - Phone:267-847-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60001122208000000X
ORMD172735208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500687986Medicaid
WA2006080Medicaid
WA8947084OtherL & I CRIME VICTIMS