Healthcare Provider Details

I. General information

NPI: 1003204983
Provider Name (Legal Business Name): NADIA QUINTANILLA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 08/01/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6974 GATEWAY BLVD E
EL PASO TX
79915-1118
US

IV. Provider business mailing address

1335 GERONIMO DR
EL PASO TX
79925-1836
US

V. Phone/Fax

Practice location:
  • Phone: 915-774-8850
  • Fax:
Mailing address:
  • Phone: 915-562-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12820
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: