Healthcare Provider Details

I. General information

NPI: 1902626872
Provider Name (Legal Business Name): LOUIS MANUEL VILLANUEVA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

903 W MARTIN ST # MS 49-2
SAN ANTONIO TX
78207-0903
US

V. Phone/Fax

Practice location:
  • Phone: 210-567-5225
  • Fax: 210-567-5169
Mailing address:
  • Phone: 201-358-5909
  • Fax: 210-358-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1179918
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1179918
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: