Basic Information
| Provider Information | |||||||||
| NPI: | 1427010883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATTILLO | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APRN GNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 JACKSON HOLE CV | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787467634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124514488 | ||||||||
| FaxNumber: | 5124532707 | ||||||||
| Practice Location | |||||||||
| Address1: | 3509 ROGGE LN | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787233640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129262070 | ||||||||
| FaxNumber: | 5129269570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 424864 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | NP7217 | 01 | TX | BLUE CROSS PROVIDER NUMBE | OTHER |