Provider Demographics
NPI:1326071838
Name:VATANADILOK, TANPRASERTH (NP)
Entity Type:Individual
Prefix:
First Name:TANPRASERTH
Middle Name:
Last Name:VATANADILOK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6157 NW LOOP 410
Mailing Address - Street 2:STE. 124
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-3302
Mailing Address - Country:US
Mailing Address - Phone:210-681-4777
Mailing Address - Fax:210-681-1887
Practice Address - Street 1:6157 NW LOOP 410
Practice Address - Street 2:STE. 124
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-3302
Practice Address - Country:US
Practice Address - Phone:210-681-4777
Practice Address - Fax:210-681-1887
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX611125363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170306808OtherWELLMED MEDICAID
TXTXB158725OtherWELLMED MEDICARE
TXP67372Medicare UPIN