Healthcare Provider Details

I. General information

NPI: 1265089692
Provider Name (Legal Business Name): BRANDON ALLEN GAUTHIER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
SAN ANTONIO TX
78234-4504
US

IV. Provider business mailing address

8314 PIONEER FLD
SAN ANTONIO TX
78253-4765
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-3482
  • Fax: 210-817-5013
Mailing address:
  • Phone: 210-792-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAP142811
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: