Provider Demographics
NPI:1629720420
Name:MIRELES, PATRICK ROSS
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:ROSS
Last Name:MIRELES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 DUVAL ST APT 113
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-3225
Mailing Address - Country:US
Mailing Address - Phone:214-906-2890
Mailing Address - Fax:
Practice Address - Street 1:1000 E 41ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-4810
Practice Address - Country:US
Practice Address - Phone:512-459-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40762183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist