Basic Information
| Provider Information | |||||||||
| NPI: | 1417465139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRAMONTEZ | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4849 N MESA ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799125919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153516600 | ||||||||
| FaxNumber: | 9153516601 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 W HAGUE RD STE 180 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799025811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153171660 | ||||||||
| FaxNumber: | 9153204848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2018 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.