Healthcare Provider Details

I. General information

NPI: 1710707583
Provider Name (Legal Business Name): RUDELAY ROQUE FERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18235 BULVERDE RD STE 105
SAN ANTONIO TX
78259-3766
US

IV. Provider business mailing address

1801 BERING DR
HOUSTON TX
77057-3194
US

V. Phone/Fax

Practice location:
  • Phone: 409-550-2054
  • Fax:
Mailing address:
  • Phone: 786-602-3546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11035953
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: