Basic Information
| Provider Information | |||||||||
| NPI: | 1073647244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PASO DEL NORTE PEDIATRICS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2325 PERSHING DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799033608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155905600 | ||||||||
| FaxNumber: | 9155907367 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 PERSHING DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799033608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155905600 | ||||||||
| FaxNumber: | 9155907367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 08/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | GUTIERREZ | ||||||||
| AuthorizedOfficialFirstName: | CARLOS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9155905600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | F8501 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 161340801 | 05 | TX | MEDICAID |