Provider Demographics
NPI:1679865265
Name:CENTENO, MAURICIO ANTONIO (LSA)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:ANTONIO
Last Name:CENTENO
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19026 STONE OAK PKWY STE 210B
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3229
Mailing Address - Country:US
Mailing Address - Phone:210-606-8213
Mailing Address - Fax:210-491-1349
Practice Address - Street 1:19026 STONE OAK PKWY STE 210B
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3229
Practice Address - Country:US
Practice Address - Phone:210-606-8213
Practice Address - Fax:210-491-1349
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-14
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00481363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12678899OtherCAQH
TXSA00481OtherSURGICAL ASSISTANT LICENSE