Provider Demographics
NPI:1467949669
Name:CARRASCO, ROZALIA ILEANA
Entity Type:Individual
Prefix:
First Name:ROZALIA
Middle Name:ILEANA
Last Name:CARRASCO
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 1:3110 NOGALITOS STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78225-2337
Mailing Address - Country:US
Mailing Address - Phone:210-533-0257
Mailing Address - Fax:210-531-9488
Practice Address - Street 1:3110 NOGALITOS STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78225-2337
Practice Address - Country:US
Practice Address - Phone:210-533-0257
Practice Address - Fax:210-531-9488
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA11945OtherTEXAS PHYSICIAN ASSISANT LICENSE