Sun City Sports Medicine and Family Clinic, PA

Primary specialty

Sports Medicine (Family Medicine) PhysicianTaxonomy code 207QS0010X

License

P1809 Issued in TX

Legal business name

SUN CITY SPORTS MEDICINE AND FAMILY CLINIC, PA

Practice address

12810 Edgemere Blvd
El Paso, TX 79938-4532

Phone

(915) 504-6955

Fax

(915) 504-6954

NPI assigned

Jun 7, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mauro ProvencioNPI 1952560682

Title

MD/Owner

Phone

(915) 525-3209

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Mauro Provencio, M.D.

  • Family Medicine Physician
  • El Paso, TX
  • NPI 1952560682
  Medicare reassignment NPD Authorized official
• Marzieh Webb, FNP-C

  • Family Nurse Practitioner
  • El Paso, TX
  • NPI 1366177263
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1339027200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718668800000",
    "number": "1114289956",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12810 EDGEMERE BLVD",
            "city": "EL PASO",
            "state": "TX",
            "postal_code": "799384532",
            "telephone_number": "915-222-8747"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12810 EDGEMERE BLVD",
            "city": "EL PASO",
            "state": "TX",
            "postal_code": "799384532",
            "telephone_number": "915-504-6955",
            "fax_number": "915-504-6954"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUN CITY SPORTS MEDICINE AND FAMILY CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-06-07",
        "last_updated": "2024-06-18",
        "certification_date": "2024-06-18",
        "status": "A",
        "authorized_official_last_name": "PROVENCIO",
        "authorized_official_first_name": "MAURO",
        "authorized_official_title_or_position": "MD/OWNER",
        "authorized_official_telephone_number": "915-525-3209"
    },
    "taxonomies": [
        {
            "code": "207QS0010X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine, Sports Medicine",
            "state": "TX",
            "license": "P1809",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sun City Orthopedics
• Sun City Orthopedics
• Sun City Pediatrics, PA
• Sun City Performing Arts Physical Therapy, LLC
• Sun City Psychological Services
• Sun City Wellness Clinic
• Sun Country Medical Equipment, Inc
• Sun Eye Care PA
• Sun Neuro PA
• Sun Orthodontix of Far East El Paso PLLC

• Sports Medicine (Family Medicine) Physician in El Paso, TX
• Providers in El Paso, TX by specialty
• Sports Medicine (Family Medicine) Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.