Healthcare Provider Details

I. General information

NPI: 1467690701
Provider Name (Legal Business Name): EDGAR ESTEBAN PORTILLO FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2009
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 S PARK AVE STE 805
TUCSON AZ
85713-5042
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-616-6760
  • Fax: 520-616-6799
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-616-1442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3259
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: