Basic Information
| Provider Information | |||||||||
| NPI: | 1578204566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACIAS | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | ENRIQUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACIAS | ||||||||
| OtherFirstName: | JORGE | ||||||||
| OtherMiddleName: | ENRIQUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1512 N ZARAGOZA RD STE B | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799368903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152130900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1512 N ZARAGOZA RD STE B | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799368903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152130900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 1073650 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LC0200X | 1073650 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine | 363LG0600X | 1073650 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1073650 | 01 | TX | NP LICENSE | OTHER |