Provider Demographics
NPI:1376196345
Name:VENCES, EDWIN JONATTAN
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:JONATTAN
Last Name:VENCES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 FROSTWOOD DR STE 1.100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-2301
Mailing Address - Country:US
Mailing Address - Phone:713-338-5519
Mailing Address - Fax:
Practice Address - Street 1:18955 N MEMORIAL DR STE 360
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4396
Practice Address - Country:US
Practice Address - Phone:281-319-8530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA14361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty