Provider Demographics
NPI:1497530877
Name:IDROGO, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:IDROGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14103 SANTA ANNA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-6577
Mailing Address - Country:US
Mailing Address - Phone:210-374-3712
Mailing Address - Fax:
Practice Address - Street 1:110 INNER CAMPUS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1139
Practice Address - Country:US
Practice Address - Phone:512-471-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program