Provider Demographics
NPI:1467690701
Name:PORTILLO, EDGAR ESTEBAN (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:ESTEBAN
Last Name:PORTILLO
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:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-616-1442
Practice Address - Street 1:3690 S PARK AVE STE 805
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-5042
Practice Address - Country:US
Practice Address - Phone:520-616-6760
Practice Address - Fax:520-616-6799
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-24
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily