Basic Information
| Provider Information | |||||||||
| NPI: | 1235248287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH TEXAS VETERANS HEALTH CARE SYSTEMS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AUDIE L. MURPHY HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 MERTON MINTER ST | ||||||||
| Address2: | 112B | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | 2106175300 | ||||||||
| Practice Location | |||||||||
| Address1: | 7400 MERTON MINTER ST | ||||||||
| Address2: | 112B | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | 2106175300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIZZIE | ||||||||
| AuthorizedOfficialFirstName: | CARLTON | ||||||||
| AuthorizedOfficialMiddleName: | JAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 2106175300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PA-C | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 286500000X | PA03282 | TX | Y | Hospitals | Military Hospital |
No ID Information.