Healthcare Provider Details

I. General information

NPI: 1467944256
Provider Name (Legal Business Name): MICHAEL PEQUENO AG-ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 BROOKLYN AVE
SAN ANTONIO TX
78212-4803
US

IV. Provider business mailing address

1200 BROOKLYN AVE
SAN ANTONIO TX
78212-4803
US

V. Phone/Fax

Practice location:
  • Phone: 210-281-9800
  • Fax: 210-281-1001
Mailing address:
  • Phone: 210-281-9800
  • Fax: 210-281-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberAP136257
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP136257
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP136257
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: