Provider Demographics
NPI:1427010883
Name:PATTILLO, MARILYN M (APRN GNP)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:M
Last Name:PATTILLO
Suffix:
Gender:F
Credentials:APRN GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 JACKSON HOLE CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7634
Mailing Address - Country:US
Mailing Address - Phone:512-451-4488
Mailing Address - Fax:512-453-2707
Practice Address - Street 1:3509 ROGGE LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3640
Practice Address - Country:US
Practice Address - Phone:512-926-2070
Practice Address - Fax:512-926-9570
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX424864363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNP7217OtherBLUE CROSS PROVIDER NUMBE
TX612061Medicare PIN
TXQ55505Medicare UPIN