Provider Demographics
NPI:1699217547
Name:MENCHACA, BLAKE (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MENCHACA
Suffix:
Gender:M
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SPURS LN
Mailing Address - Street 2:STE 230B
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1669
Mailing Address - Country:US
Mailing Address - Phone:210-690-7400
Mailing Address - Fax:210-690-7405
Practice Address - Street 1:21 SPURS LN STE 230B
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1671
Practice Address - Country:US
Practice Address - Phone:210-690-7400
Practice Address - Fax:210-690-7405
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132573363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care