Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Gustavo Carrillo

Individual provider Physician Assistant · NPI 1114542255

Gustavo Carrillo is a Physician Assistant in Salt Lake City, Utah. Qualified in 2021, 5 years ago. Practices with Mendocino Community Health Clinic Inc, a 58-clinician group and accepts Medicare assignment. Licensed in Utah.

Years since qualifying
5
Licensed in
UT
In the registry since
2020
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Practice location Address checks out

610 S 200 E Ste B
Salt Lake City, UT 84111-3802
Phone: (602) 626-4835
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X · Licence 12476377-1206 (UT)

Record details

NPI number1114542255
Entity typeIndividual (Type 1)
GenderMale
Sole proprietorNo
NPI enumeratedJune 15, 2020
Last updated in NPPESDecember 17, 2021
Certification dateNovember 17, 2021

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 2021 (5 years in practice)
Group practice Mendocino Community Health Clinic Inc — 58 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations3 on file with Medicare

Other providers in Salt Lake City