Provider Demographics
NPI:1780236000
Name:CARRILLO, PHILLIP ANDREW
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ANDREW
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 KLINE CIR APT 1
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-1046
Mailing Address - Country:US
Mailing Address - Phone:702-201-0378
Mailing Address - Fax:
Practice Address - Street 1:2702 KLINE CIR APT 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-1046
Practice Address - Country:US
Practice Address - Phone:702-201-0378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant