MEDICARE: SURELIS YOLANDA MARTINEZ CANTILLO

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	363LF0000X	Family Nurse Practitioner	1009134	TX

General Provider Information

NPI Number	:	1801629837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SURELIS YOLANDA MARTINEZ CANTILLO

Provider Business Mailing Address
First Line	:	155 ELM FOREST LOOP
Second Line	:
City	:	CEDAR CREEK
State	:	TX
Zip	:	78612-4021
Country	:	US
Telephone Number	:	512-669-2418
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 ELM FOREST LOOP
Second Line	:
City	:	CEDAR CREEK
State	:	TX
Zip	:	78612-4021
Country	:	US
Telephone Number	:	512-669-2418
Fax Number	:

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

Provider Enumeration Date	:	08/23/2024
Last Update Date	:	08/23/2024

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