MEDICARE: IRMADRIANA S TREJO-DAVIS COTA

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	224Z00000X	Occupational Therapy Assistant	215876	TX

General Provider Information

NPI Number	:	1992477228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRMADRIANA S TREJO-DAVIS COTA

Provider Business Mailing Address
First Line	:	5055 VON SCHEELE DR APT 522
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-4352
Country	:	US
Telephone Number	:	682-597-8965
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 SCHOFIELD RD BLDG 1179
Second Line	:
City	:	JBSA FT SAM HOUSTON
State	:	TX
Zip	:	78234-7577
Country	:	US
Telephone Number	:	210-808-2269
Fax Number	:	210-916-6749

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

Provider Enumeration Date	:	10/05/2021
Last Update Date	:	10/05/2021

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