MEDICARE: STEPHANIE MARIANA RICKERSON

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	363AM0700X	Medical Physician Assistant	PA15568	TX

General Provider Information

NPI Number	:	1588247639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MARIANA RICKERSON

Provider Business Mailing Address
First Line	:	1806 SUMMERWOOD DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78232-2337
Country	:	US
Telephone Number	:	713-505-2893
Fax Number	:

Provider Business Practice Location Address
First Line	:	5825 CALLAGHAN RD STE 203
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-1107
Country	:	US
Telephone Number	:	210-341-9614
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2021
Last Update Date	:	03/29/2022

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Directions to “ STEPHANIE MARIANA RICKERSON ” Practice Location

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