Provider Demographics
NPI:1457171886
Name:MAURICIO, MAXIMILIANO
Entity type:Individual
Prefix:
First Name:MAXIMILIANO
Middle Name:
Last Name:MAURICIO
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 1:8418 AVALON STAR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3646
Mailing Address - Country:US
Mailing Address - Phone:210-240-6566
Mailing Address - Fax:
Practice Address - Street 1:8418 AVALON STAR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3646
Practice Address - Country:US
Practice Address - Phone:210-240-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX711004163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse