Provider Demographics
NPI:1720138365
Name:JACOME, ELVIS G (PA-C)
Entity Type:Individual
Prefix:
First Name:ELVIS
Middle Name:G
Last Name:JACOME
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 1:7300 RANCH ROAD 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-3255
Mailing Address - Country:US
Mailing Address - Phone:512-759-8932
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:310 S MESA HILLS DR STE B
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5881
Practice Address - Country:US
Practice Address - Phone:915-351-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2018-0024363A00000X
TXPA05061363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX63429535OtherRAIL ROAD
TX209634901Medicaid
TX63429535OtherRAIL ROAD