Provider Demographics
NPI:1225591662
Name:CARRILLO, CARLOS ALFONSO
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ALFONSO
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MURCHISON DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-2931
Mailing Address - Country:US
Mailing Address - Phone:915-533-7465
Mailing Address - Fax:915-534-1185
Practice Address - Street 1:1700 MURCHISON DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-2931
Practice Address - Country:US
Practice Address - Phone:155-337-4659
Practice Address - Fax:915-534-1185
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29949363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily