Provider Demographics
NPI:1427547934
Name:CARRILLO, JANETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13460 N 94TH DR STE J1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4246
Mailing Address - Country:US
Mailing Address - Phone:623-876-8816
Mailing Address - Fax:623-298-0168
Practice Address - Street 1:13460 N 94TH DR STE J1
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4246
Practice Address - Country:US
Practice Address - Phone:623-876-8816
Practice Address - Fax:623-298-0168
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ436399Medicaid