MEDICARE: ROBERTO CORTEZ CARILLO JR. APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APN001126	NV

General Provider Information

NPI Number	:	1790916575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERTO CORTEZ CARILLO JR. APN

Provider Business Mailing Address
First Line	:	7373 PEAK DR
Second Line	:	SUITE 160
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-9003
Country	:	US
Telephone Number	:	702-869-6190
Fax Number	:	702-869-6199

Provider Business Practice Location Address
First Line	:	7373 PEAK DR
Second Line	:	SUITE 160
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-9003
Country	:	US
Telephone Number	:	702-869-6190
Fax Number	:	702-869-6199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2009
Last Update Date	:	07/28/2009

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