Provider Demographics
NPI:1023282019
Name:DECASTRO-TILSEN, SALLY E (PA)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:E
Last Name:DECASTRO-TILSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:TILSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1101 WHITE SAILS WAY
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1524
Mailing Address - Country:US
Mailing Address - Phone:949-378-8641
Mailing Address - Fax:949-760-3671
Practice Address - Street 1:400 NEWPORT CENTER DR STE 701
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7608
Practice Address - Country:US
Practice Address - Phone:949-759-8001
Practice Address - Fax:949-760-3671
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 10296363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical