MEDICARE: LUIS PONCE RN , MSN

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	163W00000X	Registered Nurse	808160	TX

General Provider Information

NPI Number	:	1265932743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS PONCE RN , MSN

Provider Business Mailing Address
First Line	:	4514 LOS RANCHITOS ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78233-6737
Country	:	US
Telephone Number	:	210-268-2632
Fax Number	:

Provider Business Practice Location Address
First Line	:	4514 LOS RANCHITOS ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78233-6737
Country	:	US
Telephone Number	:	210-268-2632
Fax Number	:

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

Provider Enumeration Date	:	02/20/2018
Last Update Date	:	02/20/2018

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