Basic Information
| Provider Information | |||||||||
| NPI: | 1710299706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRASCO | ||||||||
| FirstName: | ALONSO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 GILLHAM RD. | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167015200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2401 GILLHAM RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641084619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162343000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 54064 | MN | N | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 04-39904 | KS | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 2088P0231X | DR.0055046 | CO | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 2088P0231X | 2017002201 | MO | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | WI | MEDICAID | ENROLLED | 05 | MN | MEDICAID | P01021777 | 01 | MN | RAIL ROAD - MEDICARE | OTHER |