Provider Demographics
NPI:1528105699
Name:CUBILLOS, DENISE REBECCA (LSA)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:REBECCA
Last Name:CUBILLOS
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 VISCOUNT
Mailing Address - Street 2:PMB213
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925
Mailing Address - Country:US
Mailing Address - Phone:915-203-7894
Mailing Address - Fax:
Practice Address - Street 1:3007 KILLARNEY ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-4170
Practice Address - Country:US
Practice Address - Phone:915-203-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00116208600000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0083JROtherBCBS
TX142239400OtherUS DEPT OF LABOR