Basic Information
| Provider Information | |||||||||
| NPI: | 1467085373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE CASTRO | ||||||||
| FirstName: | MARY GRACE | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 TROUSDALE DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940104506 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 TROUSDALE DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | BURLINGAME | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940104506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6506528500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2470A2800X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | Assistant Record Technician |
No ID Information.