Provider Demographics
NPI:1093342966
Name:PALACIOS Y TREJO, IRVING A (SA-C)
Entity type:Individual
Prefix:
First Name:IRVING
Middle Name:A
Last Name:PALACIOS Y TREJO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 ADOLPH CARSON PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-7203
Mailing Address - Country:US
Mailing Address - Phone:915-329-0573
Mailing Address - Fax:
Practice Address - Street 1:1413 ADOLPH CARSON PL
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7203
Practice Address - Country:US
Practice Address - Phone:915-329-0573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20-194246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant