Provider Demographics
NPI:1336412295
Name:TIJERINA, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:TIJERINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CARRIZO SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78834-4206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:902 S 5TH ST
Practice Address - Street 2:
Practice Address - City:CARRIZO SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78834-4206
Practice Address - Country:US
Practice Address - Phone:830-876-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCONTROL #11731390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program