Healthcare Provider Details

I. General information

NPI: 1528065224
Provider Name (Legal Business Name): ROBERTO CORRAL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 S GENERAL MCMULLEN DR
SAN ANTONIO TX
78226-1190
US

IV. Provider business mailing address

1831 S GENERAL MCMULLEN DR
SAN ANTONIO TX
78226-1190
US

V. Phone/Fax

Practice location:
  • Phone: 210-434-1400
  • Fax: 210-431-7472
Mailing address:
  • Phone: 210-434-1400
  • Fax: 210-431-7472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00380
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: