MEDICARE: JOHN PAUL NIETO PA

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	363A00000X	Physician Assistant	PA12192	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA12192	OTHER	TX	STATE LICENSE

General Provider Information

NPI Number	:	1447739834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN PAUL NIETO PA

Provider Business Mailing Address
First Line	:	510 MED CT STE 210
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3484
Country	:	US
Telephone Number	:	210-494-4290
Fax Number	:	210-494-4809

Provider Business Practice Location Address
First Line	:	510 MED CT STE 210
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3484
Country	:	US
Telephone Number	:	210-494-4290
Fax Number	:	210-494-4809

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

Provider Enumeration Date	:	08/07/2018
Last Update Date	:	07/26/2024

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Directions to “ JOHN PAUL NIETO PA” Practice Location

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