Healthcare Provider Details

I. General information

NPI: 1871116962
Provider Name (Legal Business Name): EXTENSIVISTS OF TEXAS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 INDEPENDENCE DR STE 310
NEW BRAUNFELS TX
78132-3982
US

IV. Provider business mailing address

PO BOX 310332
NEW BRAUNFELS TX
78131-0332
US

V. Phone/Fax

Practice location:
  • Phone: 830-730-5025
  • Fax: 830-730-4207
Mailing address:
  • Phone: 830-730-8580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: VERONICA HARLAN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 830-730-5025