Healthcare Provider Details

I. General information

NPI: 1215459565
Provider Name (Legal Business Name): RICARDO J REQUENEZ NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/21/2022
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 E MAIN ST STE 102
ALICE TX
78332-4188
US

IV. Provider business mailing address

2510 E MAIN ST STE 102
ALICE TX
78332-4188
US

V. Phone/Fax

Practice location:
  • Phone: 361-664-4445
  • Fax: 361-664-4449
Mailing address:
  • Phone: 361-664-4445
  • Fax: 361-664-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP134359
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: