MEDICARE: MRS. MEENU MIRELES PA-C

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	363AM0700X	Medical Physician Assistant	PA01878	TX

General Provider Information

NPI Number	:	1851380869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MEENU MIRELES PA-C

Provider Business Mailing Address
First Line	:	3551 ROGER BROOKE DR
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-4504
Country	:	US
Telephone Number	:	210-539-9582
Fax Number	:

Provider Business Practice Location Address
First Line	:	3051 GARDEN AVE
Second Line	:	SUITE 159 BLDG 1279
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-7598
Country	:	US
Telephone Number	:	210-295-4843
Fax Number	:

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

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	08/26/2020

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