MEDICARE: MARY G GRACIA

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	363LP0200X	Pediatric Nurse Practitioner	AP105341	TX
2	163W00000X	Registered Nurse	525473	TX

General Provider Information

NPI Number	:	1144211806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY G GRACIA

Provider Business Mailing Address
First Line	:	1 BOONE RD
Second Line	:
City	:	BREMERTON
State	:	WA
Zip	:	98312-1894
Country	:	US
Telephone Number	:	360-475-4426
Fax Number	:	360-475-4344

Provider Business Practice Location Address
First Line	:	17026 BULVERDE RD STE 105
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78247-3176
Country	:	US
Telephone Number	:	210-981-5543
Fax Number	:	972-980-3738

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	03/11/2026

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Directions to “ MARY G GRACIA ” Practice Location

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