Provider Demographics
NPI:1720828429
Name:RODRIGUEZ-CARRILLO, JESUS IVAN (FNP-BC)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:IVAN
Last Name:RODRIGUEZ-CARRILLO
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7423 SILVERTHORNE RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3753
Mailing Address - Country:US
Mailing Address - Phone:575-644-3509
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST # 10065
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:575-644-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81732163WE0003X
NY355152363LF0000X
NY941836163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163W00000XNursing Service ProvidersRegistered Nurse