Provider Demographics
NPI:1285133512
Name:EL PASO ADVANCE PRACTICE PROVIDER, PLLC
Entity type:Organization
Organization Name:EL PASO ADVANCE PRACTICE PROVIDER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TARON
Authorized Official - Middle Name:TARAY
Authorized Official - Last Name:PEEBLES
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:915-532-2477
Mailing Address - Street 1:1605 GEORGE DIETER DR STE 636
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-5600
Mailing Address - Country:US
Mailing Address - Phone:915-671-1371
Mailing Address - Fax:915-219-9022
Practice Address - Street 1:5080 POWDER RIVER LN
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-8286
Practice Address - Country:US
Practice Address - Phone:915-328-2311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343800000X
TX121725363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No343800000XTransportation ServicesSecured Medical Transport (VAN)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1437423696Medicaid