=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033512868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIETTA BERMUDEZ GUAJARDO FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 08/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7913 BANDERA RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78250-6511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-698-9841
-----------------------------------------------------
Fax | 210-698-9863
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7913 BANDERA RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78250-6511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-698-9841
-----------------------------------------------------
Fax | 210-698-9863
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | NP95005262
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP126286
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------