Provider Demographics
NPI:1861575318
Name:TREVINO, LISA VERONICA (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:VERONICA
Last Name:TREVINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34717
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78265-4717
Mailing Address - Country:US
Mailing Address - Phone:210-615-1187
Mailing Address - Fax:210-614-2180
Practice Address - Street 1:4242 MEDICAL DR
Practice Address - Street 2:SUITE 3100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5640
Practice Address - Country:US
Practice Address - Phone:210-615-1187
Practice Address - Fax:210-614-2180
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04900363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185347501Medicaid
TX8Y0782OtherBLUECROSS/BLUESHIELD TX.
TX185347501Medicaid
TX8J2874Medicare PIN