MEDICARE: MR. RALPH STALEY JR. FIRST ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant

General Provider Information

NPI Number	:	1134353261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RALPH STALEY JR. FIRST ASSISTANT

Provider Business Mailing Address
First Line	:	1234 SONESTA LN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78260-2462
Country	:	US
Telephone Number	:	210-254-7993
Fax Number	:	210-499-4405

Provider Business Practice Location Address
First Line	:	1234 SONESTA LN
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78260-2462
Country	:	US
Telephone Number	:	210-254-7993
Fax Number	:	210-499-4405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2009
Last Update Date	:	03/30/2023

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