Provider Demographics
NPI:1669476222
Name:CARRILLO, PATTI A (PT)
Entity Type:Individual
Prefix:
First Name:PATTI
Middle Name:A
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 WESTWIND DR
Mailing Address - Street 2:STE 310
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-1743
Mailing Address - Country:US
Mailing Address - Phone:915-544-2455
Mailing Address - Fax:915-544-3149
Practice Address - Street 1:7430 REMCON CIR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-3514
Practice Address - Country:US
Practice Address - Phone:915-544-0051
Practice Address - Fax:915-584-6764
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1059079225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1589947-02Medicaid
TX1589947-02Medicaid
TX8B6475Medicare ID - Type Unspecified