Healthcare Provider Details

I. General information

NPI: 1497530877
Provider Name (Legal Business Name): HALEY IDROGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2023
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 INNER CAMPUS DR
AUSTIN TX
78712-1139
US

IV. Provider business mailing address

14103 SANTA ANNA WAY
SAN ANTONIO TX
78253-6577
US

V. Phone/Fax

Practice location:
  • Phone: 512-471-3434
  • Fax:
Mailing address:
  • Phone: 210-374-3712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: