Healthcare Provider Details

I. General information

NPI: 1659069318
Provider Name (Legal Business Name): WILHELM VINICIO CARRANZA STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 S BONHAM ST
MEXIA TX
76667-3600
US

IV. Provider business mailing address

990 E 3200 N
NORTH OGDEN UT
84414-1767
US

V. Phone/Fax

Practice location:
  • Phone: 254-562-9321
  • Fax: 254-562-3570
Mailing address:
  • Phone: 323-637-1741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19770
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19770
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: