Provider Demographics
NPI:1457942633
Name:VIDAL, PAIGE RAQUEL
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:RAQUEL
Last Name:VIDAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:
Other - Last Name:VIDAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1276 HIGH HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CANYON LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:78133-6905
Mailing Address - Country:US
Mailing Address - Phone:210-275-6678
Mailing Address - Fax:
Practice Address - Street 1:1000 OLD HICO RD APT 904
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-9515
Practice Address - Country:US
Practice Address - Phone:210-275-6678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program