Provider Demographics
NPI:1578204566
Name:MACIAS, JORGE ENRIQUE (NP)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:ENRIQUE
Last Name:MACIAS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:JORGE
Other - Middle Name:ENRIQUE
Other - Last Name:MACIAS
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1512 N ZARAGOZA RD STE B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-8903
Mailing Address - Country:US
Mailing Address - Phone:915-213-0900
Mailing Address - Fax:
Practice Address - Street 1:1512 N ZARAGOZA RD STE B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8903
Practice Address - Country:US
Practice Address - Phone:915-213-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1073650363LA2100X, 363LC0200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1073650OtherNP LICENSE