Healthcare Provider Details

I. General information

NPI: 1164092458
Provider Name (Legal Business Name): NOEL ROLDAN BUENO JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 TEXAN TRL STE 250
CORPUS CHRISTI TX
78411-2526
US

IV. Provider business mailing address

601 TEXAN TRL STE 300
CORPUS CHRISTI TX
78411-2549
US

V. Phone/Fax

Practice location:
  • Phone: 361-854-0811
  • Fax: 361-806-5040
Mailing address:
  • Phone: 361-854-0811
  • Fax: 361-806-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4060798
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: