Healthcare Provider Details

I. General information

NPI: 1811340490
Provider Name (Legal Business Name): PETRA DE LEON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 E SAN PATRICIO AVE
MATHIS TX
78368-2402
US

IV. Provider business mailing address

PO BOX 61160
CORPUS CHRISTI TX
78466-1160
US

V. Phone/Fax

Practice location:
  • Phone: 361-453-4470
  • Fax: 800-621-5209
Mailing address:
  • Phone: 361-884-2904
  • Fax: 361-371-8376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP131476
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: