Provider Demographics
NPI:1770582173
Name:MAZUCA, MARICELA A (PA)
Entity type:Individual
Prefix:
First Name:MARICELA
Middle Name:A
Last Name:MAZUCA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 E. SONTERRA BLVD SUITE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-305-5075
Mailing Address - Fax:830-730-5082
Practice Address - Street 1:1202 E. SONTERRA BLVD SUITE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-271-3203
Practice Address - Fax:210-733-6983
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03610363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N4388OtherBCBS
TX8B4596Medicare ID - Type Unspecified
P90546Medicare UPIN