Healthcare Provider Details

I. General information

NPI: 1689170482
Provider Name (Legal Business Name): MAYRA ALEXANDRA PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

IV. Provider business mailing address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-6810
  • Fax: 210-450-6801
Mailing address:
  • Phone: 210-450-6810
  • Fax: 210-450-6801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberS9379
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: