Provider Demographics
NPI:1508879305
Name:CARRILLO, ROBERT V (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:V
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 WOODLAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT SCOTT
Mailing Address - State:KS
Mailing Address - Zip Code:66701-8797
Mailing Address - Country:US
Mailing Address - Phone:620-223-2200
Mailing Address - Fax:
Practice Address - Street 1:401 WOODLAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-8797
Practice Address - Country:US
Practice Address - Phone:620-223-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54133367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS145207OtherBLUE CROSS, PC
KS145207OtherBLUE CROSS, PC