Basic Information
| Provider Information | |||||||||
| NPI: | 1497051478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 E QUINCY ST | ||||||||
| Address2: | SUITE B100 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782152039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102998000 | ||||||||
| FaxNumber: | 2102998099 | ||||||||
| Practice Location | |||||||||
| Address1: | 9102 FLOYD CURL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107829528 | ||||||||
| FaxNumber: | 5125970841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA06859 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | TXB157669 | 01 | TX | MEDICARE PTAN | OTHER |