Healthcare Provider Details

I. General information

NPI: 1962187633
Provider Name (Legal Business Name): SERGIO ENRIQUE CARRILLO JR. FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 ALAMEDA AVE
EL PASO TX
79905-2705
US

IV. Provider business mailing address

4845 ALAMEDA AVE
EL PASO TX
79905-2705
US

V. Phone/Fax

Practice location:
  • Phone: 915-298-5444
  • Fax:
Mailing address:
  • Phone: 915-298-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1115821
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1115821
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: