Basic Information
| Provider Information | |||||||||
| NPI: | 1417382094 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CACERES | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | JAVIER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 801 S MAIN ST | ||||||||
| Address2: | STE C | ||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785015055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566860574 | ||||||||
| FaxNumber: | 9566863301 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 S MAIN ST | ||||||||
| Address2: | STE C | ||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785015055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566860574 | ||||||||
| FaxNumber: | 9566863301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2013 | ||||||||
| LastUpdateDate: | 02/27/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP123911 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 332385YLPS | 01 | TX | WELLMED PTAN | OTHER | 346227703 | 05 | TX | MEDICAID |