Provider Demographics
NPI:1780167932
Name:BOCANEGRA, GLORIA LORRAINE
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:LORRAINE
Last Name:BOCANEGRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 MCALPIN DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3339
Mailing Address - Country:US
Mailing Address - Phone:361-658-6151
Mailing Address - Fax:
Practice Address - Street 1:2322 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1947
Practice Address - Country:US
Practice Address - Phone:361-882-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2122042225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant