Provider Demographics
NPI:1629011085
Name:PEREZ, LUIS DANIEL (PA)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:DANIEL
Last Name:PEREZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 BROOKLYN AVE
Mailing Address - Street 2:320
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4803
Mailing Address - Country:US
Mailing Address - Phone:210-396-5310
Mailing Address - Fax:210-396-5316
Practice Address - Street 1:1200 BROOKLYN AVE
Practice Address - Street 2:320
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4803
Practice Address - Country:US
Practice Address - Phone:210-396-5310
Practice Address - Fax:210-396-5316
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA03892Medicaid
TX8N4701OtherBCBS
TX7863511OtherAETNA
TXP00217741OtherRAILROAD MEDICARE
TXP00217741OtherRAILROAD MEDICARE
TXPA03892Medicaid