Healthcare Provider Details

I. General information

NPI: 1356043756
Provider Name (Legal Business Name): NICHOLAS ANDRE SAN ROMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 49TH ST
AUSTIN TX
78756-3126
US

IV. Provider business mailing address

1100 W 49TH ST
AUSTIN TX
78756-3126
US

V. Phone/Fax

Practice location:
  • Phone: 512-776-7111
  • Fax:
Mailing address:
  • Phone: 512-776-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberW1497
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: