MEDICARE: OLEGARIO CARRILLO PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	870	AK

General Provider Information

NPI Number	:	1417946039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLEGARIO CARRILLO PA-C

Provider Business Mailing Address
First Line	:	4320 DIPLOMACY DR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5925
Country	:	US
Telephone Number	:	907-729-4245
Fax Number	:

Provider Business Practice Location Address
First Line	:	4320 DIPLOMACY DR
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-5925
Country	:	US
Telephone Number	:	907-729-4245
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	04/16/2014

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