Healthcare Provider Details

I. General information

NPI: 1073299236
Provider Name (Legal Business Name): NICOLE BERTRAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N SAN SABA STE 201A
SAN ANTONIO TX
78207-3120
US

IV. Provider business mailing address

PO BOX 650002 DEPT 8286
DALLAS TX
75265-0029
US

V. Phone/Fax

Practice location:
  • Phone: 210-547-3430
  • Fax:
Mailing address:
  • Phone: 210-615-6626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17014
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: