Healthcare Provider Details

I. General information

NPI: 1285503904
Provider Name (Legal Business Name): MRS. ALYSSA R RUSSOMANNO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 CULEBRA RD
SAN ANTONIO TX
78228-5914
US

IV. Provider business mailing address

3615 CULEBRA RD
SAN ANTONIO TX
78228-5914
US

V. Phone/Fax

Practice location:
  • Phone: 210-314-6473
  • Fax: 210-314-8676
Mailing address:
  • Phone: 210-314-6473
  • Fax: 210-314-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number51399-0325
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number51444-0325
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: