Healthcare Provider Details

I. General information

NPI: 1093342966
Provider Name (Legal Business Name): IRVING A PALACIOS Y TREJO SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 ADOLPH CARSON PL
EL PASO TX
79936-7203
US

IV. Provider business mailing address

1413 ADOLPH CARSON PL
EL PASO TX
79936-7203
US

V. Phone/Fax

Practice location:
  • Phone: 915-329-0573
  • Fax:
Mailing address:
  • Phone: 915-329-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number20-194
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: