MEDICARE: MOUNGER NP FIRST ASSIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1073162160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNGER NP FIRST ASSIST

Provider Business Mailing Address
First Line	:	12014 FORT LEATON
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-6363
Country	:	US
Telephone Number	:	973-865-2944
Fax Number	:

Provider Business Practice Location Address
First Line	:	12014 FORT LEATON
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78254-6363
Country	:	US
Telephone Number	:	973-865-2944
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WILMER KYLE MOUNGER
Credential	:	AGACNP
Telephone Number	:	973-865-2944

Provider Enumeration Date	:	09/10/2019
Last Update Date	:	09/10/2019

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