Provider Demographics
NPI:1821229717
Name:PRO PHYSICIANS CLINIC, PA
Entity Type:Organization
Organization Name:PRO PHYSICIANS CLINIC, PA
Other - Org Name:PRO PHYSICIANS CLINIC, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRYGGESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-886-8730
Mailing Address - Street 1:8019 S NEW BRAUNFELS STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78235-1069
Mailing Address - Country:US
Mailing Address - Phone:210-816-4770
Mailing Address - Fax:210-816-4771
Practice Address - Street 1:12705 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3257
Practice Address - Country:US
Practice Address - Phone:210-816-4770
Practice Address - Fax:210-816-4771
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO PHYSICIANS CLINIC, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-27
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3406OtherMEDICARE PTAN