Healthcare Provider Details

I. General information

NPI: 1699163642
Provider Name (Legal Business Name): ELISE VADER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2014
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 LOCKE ST
SAN ANTONIO TX
78208-2127
US

IV. Provider business mailing address

PO BOX 734812
DALLAS TX
75373-4812
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-8255
  • Fax: 210-644-8726
Mailing address:
  • Phone: 210-358-9500
  • Fax: 210-358-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09491
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: