Provider Demographics
NPI:1134347289
Name:BERREZUETA, ROMULO ALFONSO (PA)
Entity type:Individual
Prefix:MR
First Name:ROMULO
Middle Name:ALFONSO
Last Name:BERREZUETA
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 1:2258 WILLOW TRL
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-3881
Mailing Address - Country:US
Mailing Address - Phone:830-773-0898
Mailing Address - Fax:
Practice Address - Street 1:2176 E GARRISON ST STE C
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5072
Practice Address - Country:US
Practice Address - Phone:830-773-3353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH02188Medicare UPIN
TX8A1572Medicare ID - Type Unspecified