Provider Demographics
NPI:1952993396
Name:CARRILLO, KELCEY MUMBOWER (PA-C)
Entity type:Individual
Prefix:
First Name:KELCEY
Middle Name:MUMBOWER
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9330 TYLER OAKS
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4190
Mailing Address - Country:US
Mailing Address - Phone:210-723-6401
Mailing Address - Fax:
Practice Address - Street 1:1051 OLD US HWY 90 E
Practice Address - Street 2:
Practice Address - City:CASTROVILLE
Practice Address - State:TX
Practice Address - Zip Code:78009
Practice Address - Country:US
Practice Address - Phone:830-931-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant