Basic Information
| Provider Information | |||||||||
| NPI: | 1578024527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROVAGNA | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 BRACKENRIDGE AVE APT 1202 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782097015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342609029 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109166463 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2019 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 010127064 | VA | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.