=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376363945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELI JOHN DESARNO DNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2024
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 E EUCLID AVE
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78212-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-581-2829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5503 RESEARCH DR APT 6101
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78240-5075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-315-5162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 1178169
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------