Basic Information
| Provider Information | |||||||||
| NPI: | 1912500802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PADILLA | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | ALFREDO | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2112 DUSK CREEK PL | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799113133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9153837562 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6028 SURETY DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155443500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2020 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 61943 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 1027095 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.