Healthcare Provider Details

I. General information

NPI: 1134875669
Provider Name (Legal Business Name): MARCUS RENE AYALA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11212 HIGHWAY 151 STE 100
SAN ANTONIO TX
78251-4500
US

IV. Provider business mailing address

11212 HIGHWAY 151 STE 100
SAN ANTONIO TX
78251-4500
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-9900
  • Fax: 210-450-9901
Mailing address:
  • Phone: 210-450-9900
  • Fax: 210-450-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8639
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15396
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: