Provider Demographics
NPI:1215593892
Name:LANDA, JORGE HUMBERTO JR (CSFA)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:HUMBERTO
Last Name:LANDA
Suffix:JR
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11170 CANDLE PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-4207
Mailing Address - Country:US
Mailing Address - Phone:956-744-0135
Mailing Address - Fax:
Practice Address - Street 1:20659 STONE OAK PKWY APT 1810
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-7534
Practice Address - Country:US
Practice Address - Phone:956-744-0135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-19
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX188850246ZC0007X
TX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant