Healthcare Provider Details

I. General information

NPI: 1255381406
Provider Name (Legal Business Name): PATRICIO A ILABACA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6027 WALNUT GROVE RD SUITE 114
MEMPHIS TN
38120-2145
US

IV. Provider business mailing address

6027 WALNUT GROVE SUITE 203
MEMPHIS TN
38120
US

V. Phone/Fax

Practice location:
  • Phone: 901-683-6161
  • Fax: 901-683-7998
Mailing address:
  • Phone: 901-683-6161
  • Fax: 901-683-3915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number9582
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: