Basic Information
Provider Information | |||||||||
NPI: | 1053919308 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CGN EPENT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5959 GATEWAY BLVD W STE 160 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799253315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9157795866 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5959 GATEWAY BLVD W STE 160 | ||||||||
Address2: |   | ||||||||
City: | EL PASO | ||||||||
State: | TX | ||||||||
PostalCode: | 799253315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9157795866 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2020 | ||||||||
LastUpdateDate: | 12/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GONZALES | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING/CREDENTIALING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 9157795866 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 153157602 | 05 | TX |   | MEDICAID | 326176001 | 05 | TX |   | MEDICAID | 118690001 | 05 | TX |   | MEDICAID |