MEDICARE: ROY DEREK BALDERAS

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	225200000X	Physical Therapy Assistant	2007977	TX

General Provider Information

NPI Number	:	1700368370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY DEREK BALDERAS

Provider Business Mailing Address
First Line	:	6023 WOOD PASS
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78249-1922
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5757 N KNOLL
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-2239
Country	:	US
Telephone Number	:	210-699-8535
Fax Number	:	210-699-8674

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

Provider Enumeration Date	:	08/30/2018
Last Update Date	:	08/30/2018

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Directions to “ ROY DEREK BALDERAS ” Practice Location

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