Healthcare Provider Details

I. General information

NPI: 1487024279
Provider Name (Legal Business Name): GOLDEN EAGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N SANTA ROSA
SAN ANTONIO TX
78207-3108
US

IV. Provider business mailing address

14041 NORTHWEST BLVD STE 1
CORPUS CHRISTI TX
78410-5138
US

V. Phone/Fax

Practice location:
  • Phone: 210-704-3030
  • Fax:
Mailing address:
  • Phone: 361-767-9963
  • Fax: 361-767-8477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP129167
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP129167
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number777367
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number777367
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: