Provider Demographics
NPI:1275127979
Name:BORNIO CARRILLO, LILIAN RENATA
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:RENATA
Last Name:BORNIO CARRILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:503-294-4321
Practice Address - Street 1:16463 BOONES FERRY RD STE 300
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4376
Practice Address - Country:US
Practice Address - Phone:503-658-9351
Practice Address - Fax:541-708-5934
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA211394363A00000X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program