Healthcare Provider Details

I. General information

NPI: 1649632266
Provider Name (Legal Business Name): LAURA REQUENEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17766 VERDE PKWY STE 230
SELMA TX
78154-2226
US

IV. Provider business mailing address

17766 VERDE PKWY STE 230
SELMA TX
78154-2226
US

V. Phone/Fax

Practice location:
  • Phone: 201-998-2410
  • Fax:
Mailing address:
  • Phone: 201-998-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09836
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: