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General NPI Number Information
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NPI Number | 1063739381
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Entity Type | Individual
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Provider Name | CASEY ANNE PORTILLO P.A. - C
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Gender | Female
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Dates
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Enumeration Date | 04/26/2010
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Last Update Date | 04/08/2022
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Provider Practice Location Address
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Address Line | 1935 MEDICAL DISTRICT DR PAVILLION 3RD FLOOR
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City | DALLAS
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State | TX
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Zip | 75235-7701
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Country | US
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Telephone | 214-456-1798
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Fax |
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Provider Business Mailing Address
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Address Line | 8201 MEMORIAL LN #2022
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City | PLANO
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State | TX
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Zip | 75024-2253
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA03803
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License Number State | TX
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