Provider Demographics
NPI:1689173643
Name:CARRILLO, RICARDO DANIEL (CRNA)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:DANIEL
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 1:1356 GEMA MARIE PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79928-5281
Mailing Address - Country:US
Mailing Address - Phone:915-240-9658
Mailing Address - Fax:
Practice Address - Street 1:1625 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5005
Practice Address - Country:US
Practice Address - Phone:915-747-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX785570163WC0200X
TXAP136449367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine