1154602514 NPI number — LE'JON P TERAN APN

Table of content: LE'JON P TERAN APN (NPI 1154602514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154602514 NPI number — LE'JON P TERAN APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TERAN
Provider First Name:
LE'JON
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154602514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4330 MEDICAL DR
Provider Second Line Business Mailing Address:
STE 500
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-576-5306
Provider Business Mailing Address Fax Number:
210-694-0645

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4330 MEDICAL DR
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-3342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-576-5306
Provider Business Practice Location Address Fax Number:
210-694-0645
Provider Enumeration Date:
08/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP115937 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 674307 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB155211 . This is a "WELLMED MEDICAL GROUP PA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: A0155356 . This is a "DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 283859YMVU . This is a "WELLMED NETWORKS INC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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