Healthcare Provider Details

I. General information

NPI: 1104583582
Provider Name (Legal Business Name): JESUS MAURICIO ACERO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2021
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4338 W THOMAS RD # 116
PHOENIX AZ
85031-3878
US

IV. Provider business mailing address

1423 PARK WIND DR
KATY TX
77450-4643
US

V. Phone/Fax

Practice location:
  • Phone: 623-385-7900
  • Fax:
Mailing address:
  • Phone: 409-419-8908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1141
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9645
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: