Provider Demographics
NPI:1912356197
Name:GAULTNEY, NICHOLAS (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GAULTNEY
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 591245
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0112
Mailing Address - Country:US
Mailing Address - Phone:210-985-1900
Mailing Address - Fax:210-985-1905
Practice Address - Street 1:14603 HUEBNER RD STE 3505
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5469
Practice Address - Country:US
Practice Address - Phone:210-985-1900
Practice Address - Fax:210-985-1905
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX859829363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health