Healthcare Provider Details

I. General information

NPI: 1316790603
Provider Name (Legal Business Name): KOURTNEY ALEXANDRA GWIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
SAN ANTONIO TX
78234-4504
US

IV. Provider business mailing address

8019 INDIAN CREEK DR
ORANGEVALE CA
95662-2140
US

V. Phone/Fax

Practice location:
  • Phone: 916-757-7470
  • Fax:
Mailing address:
  • Phone: 916-757-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberBP10090843
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: