Healthcare Provider Details

I. General information

NPI: 1942900295
Provider Name (Legal Business Name): MARK CHRISTOPHER GWIN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W RECTOR ST
SAN ANTONIO TX
78216-5718
US

IV. Provider business mailing address

903 W MARTIN ST
SAN ANTONIO TX
78207-0903
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-0800
  • Fax: 210-358-0850
Mailing address:
  • Phone: 210-358-0572
  • Fax: 210-358-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1124686
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: