Healthcare Provider Details

I. General information

NPI: 1386634921
Provider Name (Legal Business Name): ROBERT LEE HERROLD FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TMC, MCWETHY FORT SAM HOUSTON
SAN ANTONIO TX
78234-6000
US

IV. Provider business mailing address

5130 SPRING ARROW
SAN ANTONIO TX
78247-1821
US

V. Phone/Fax

Practice location:
  • Phone: 210-295-4204
  • Fax:
Mailing address:
  • Phone: 210-295-4204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR136851
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: