Healthcare Provider Details

I. General information

NPI: 1134347289
Provider Name (Legal Business Name): ROMULO ALFONSO BERREZUETA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2176 E GARRISON ST STE C
EAGLE PASS TX
78852-5072
US

IV. Provider business mailing address

2258 WILLOW TRL
EAGLE PASS TX
78852-3881
US

V. Phone/Fax

Practice location:
  • Phone: 830-773-3353
  • Fax:
Mailing address:
  • Phone: 830-773-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00155
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: