Provider Demographics
NPI:1669484085
Name:ORTEGA, CARLOS (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:ORTEGA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N CLAYTON ST
Mailing Address - Street 2:MEDICAL OFFICE BLDG 401
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-3165
Mailing Address - Country:US
Mailing Address - Phone:302-421-4800
Mailing Address - Fax:302-421-4189
Practice Address - Street 1:701 N CLAYTON ST
Practice Address - Street 2:MEDICAL OFFICE BLDG 401
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3165
Practice Address - Country:US
Practice Address - Phone:302-421-4800
Practice Address - Fax:302-421-4189
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000352363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P71872OtherBLUE SHIELD DE
P71872Medicare UPIN