Provider Demographics
NPI:1003547332
Name:BRISENO, JEREMIAS LEODAN (PA)
Entity type:Individual
Prefix:
First Name:JEREMIAS
Middle Name:LEODAN
Last Name:BRISENO
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:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-1614
Mailing Address - Country:US
Mailing Address - Phone:956-362-8500
Mailing Address - Fax:956-362-8529
Practice Address - Street 1:5519 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-5563
Practice Address - Country:US
Practice Address - Phone:956-362-8500
Practice Address - Fax:956-362-8529
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA17764363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant