Provider Demographics
NPI:1568854537
Name:PRASAD, MARYKUTTY (RN,FNP)
Entity Type:Individual
Prefix:
First Name:MARYKUTTY
Middle Name:
Last Name:PRASAD
Suffix:
Gender:F
Credentials:RN,FNP
Other - Prefix:
Other - First Name:MARYKUTTY
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22135 I H- 10 W CVS MINUTE CLINIC
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-3301
Mailing Address - Country:US
Mailing Address - Phone:210-698-1643
Mailing Address - Fax:
Practice Address - Street 1:22135 W INTERSTATE 10
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1621
Practice Address - Country:US
Practice Address - Phone:210-219-2246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX699647364SC0200X
TXAP120772363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine