Provider Demographics
NPI:1134628563
Name:ILOG, VICTOR LEE (FNP)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:LEE
Last Name:ILOG
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6028 SURETY DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2018
Mailing Address - Country:US
Mailing Address - Phone:915-544-3500
Mailing Address - Fax:
Practice Address - Street 1:6028 SURETY DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2018
Practice Address - Country:US
Practice Address - Phone:915-544-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03539363LF0000X, 363LP0808X
TXAP136515363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily