Healthcare Provider Details

I. General information

NPI: 1699217547
Provider Name (Legal Business Name): BLAKE MENCHACA AG-ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6720 BERTNER AVE
HOUSTON TX
77030-2604
US

IV. Provider business mailing address

21 SPURS LN STE 230B
SAN ANTONIO TX
78240-1669
US

V. Phone/Fax

Practice location:
  • Phone: 823-355-2666
  • Fax:
Mailing address:
  • Phone: 210-690-7400
  • Fax: 210-690-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAP132573
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP132573
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: