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General NPI Number Information
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NPI Number | 1104238450
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Entity Type | Individual
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Provider Name | RICHARD THORNELL SR.
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Gender | Male
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Dates
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Enumeration Date | 05/21/2014
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Last Update Date | 12/13/2018
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Provider Practice Location Address
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Address Line | 11634 PURPLE MINT
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City | SAN ANTONIO
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State | TX
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Zip | 78245-3369
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Country | US
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Telephone | 210-219-7332
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 WILFORD HALL LOOP BLDG 4554
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City | JBSA LACKLAND
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State | TX
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Zip | 78236-5638
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Country | US
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Telephone | 210-292-7603
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | AP124687
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License Number State | TX
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