Basic Information
| Provider Information | |||||||||
| NPI: | 1417521014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGONIGAL | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | WILSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1716 | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760630010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177815953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7272 WURZBACH RD STE 706 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2021 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 1038376 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.