Healthcare Provider Details

I. General information

NPI: 1154642619
Provider Name (Legal Business Name): AMANDA LEE TREVINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N SANTA ROSA CENTER FOR CHILDREN & FAMILES, 4TH FLOOR
SAN ANTONIO TX
78207-3108
US

IV. Provider business mailing address

333 N SANTA ROSA CENTER FOR CHILDREN & FAMILIES, SUITE 4703
SAN ANTONIO TX
78207-3108
US

V. Phone/Fax

Practice location:
  • Phone: 210-704-4140
  • Fax: 210-704-4136
Mailing address:
  • Phone: 210-704-2575
  • Fax: 210-704-2545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP1-0038082
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: