Healthcare Provider Details

I. General information

NPI: 1093414534
Provider Name (Legal Business Name): NIKKI LAUDERBACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
SAN ANTONIO TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-4789
  • Fax: 210-916-6654
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberV4138
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: