Healthcare Provider Details

I. General information

NPI: 1730154881
Provider Name (Legal Business Name): JOSEPH MERAN BLYDENBURGH JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2961 MOSSROCK
SAN ANTONIO TX
78230-5119
US

IV. Provider business mailing address

2961 MOSSROCK
SAN ANTONIO TX
78230-5119
US

V. Phone/Fax

Practice location:
  • Phone: 210-731-4800
  • Fax: 210-731-4810
Mailing address:
  • Phone: 210-731-4800
  • Fax: 210-731-4810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01457
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: