Basic Information
Provider Information | |||||||||
NPI: | 1114971058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASTLE | ||||||||
FirstName: | WESLEY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 846098 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752846098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9033246450 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1327 TROUP HWY | ||||||||
Address2: |   | ||||||||
City: | TYLER | ||||||||
State: | TX | ||||||||
PostalCode: | 757014443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9035108840 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2006 | ||||||||
LastUpdateDate: | 10/10/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 001130 | IA | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 363A00000X | PA04931 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | TIN PLUS 021 | 01 | TX | TRICARE | OTHER | P00128999 | 01 | IA | RR MEDICARE | OTHER | 8Y8942 | 01 | TX | BCBS OF TEXAS | OTHER | P00075075 | 01 | IA | RR MEDICARE | OTHER |