Basic Information
| Provider Information | |||||||||
| NPI: | 1952592487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONSTANTINO | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615739181 | ||||||||
| FaxNumber: | 3615725126 | ||||||||
| Practice Location | |||||||||
| Address1: | 2701 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615739181 | ||||||||
| FaxNumber: | 3615725126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2007 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05051 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 198870103 | 05 | TX | MEDICAID | 198870104 | 05 | TX | MEDICAID | 198870102 | 05 | TX | MEDICAID |