Provider Demographics
NPI:1497051478
Name:RODRIGUEZ, AUDREY DIANE (PA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:DIANE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:215 E QUINCY ST
Mailing Address - Street 2:SUITE B100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-2039
Mailing Address - Country:US
Mailing Address - Phone:210-299-8000
Mailing Address - Fax:210-299-8099
Practice Address - Street 1:9102 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1553
Practice Address - Country:US
Practice Address - Phone:210-782-9528
Practice Address - Fax:512-597-0841
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA06859363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB157669OtherMEDICARE PTAN