Basic Information
| Provider Information | |||||||||
| NPI: | 1649632266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REQUENEZ | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783324822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613960370 | ||||||||
| FaxNumber: | 3616642248 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 GENERAL CAVAZOS BLVD | ||||||||
| Address2: | 303 AND C | ||||||||
| City: | KINGSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783637150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615923237 | ||||||||
| FaxNumber: | 8557854465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2016 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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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 | PA09836 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 742557428 | 01 | TX | GROUP TAX ID | OTHER | 741679824 | 01 | TX | GROUP TAX ID | OTHER |