Basic Information
| Provider Information | |||||||||
| NPI: | 1508963075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELIU | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1626 MEDICAL CENTER DR STE 400 | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799025000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155469200 | ||||||||
| FaxNumber: | 9155469800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 MEDICAL CENTER DR STE 400 | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799025000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155469200 | ||||||||
| FaxNumber: | 9155469800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 06/09/2010 | ||||||||
| 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 | 363A00000X | PA03666 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 193595901 | 05 | TX | MEDICAID | 193595902 | 05 | TX | MEDICAID | 47924233 | 05 | NM | MEDICAID |