Provider Demographics
NPI:1932791878
Name:ESTRADA, MANUEL
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:ESTRADA
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 1:1605 GEORGE DIETER DR STE 636
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5692
Mailing Address - Country:US
Mailing Address - Phone:915-671-1371
Mailing Address - Fax:915-219-9022
Practice Address - Street 1:8825 N LOOP DR STE 103
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79907-4607
Practice Address - Country:US
Practice Address - Phone:915-201-0199
Practice Address - Fax:915-233-3053
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX894954363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health