Basic Information
Provider Information | |||||||||
NPI: | 1508958349 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOONE | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | SANCHEZ | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANCHEZ | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3551 ROGER BROOKE DR | ||||||||
Address2: |   | ||||||||
City: | FORT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 782344504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105399582 | ||||||||
FaxNumber: | 2109165102 | ||||||||
Practice Location | |||||||||
Address1: | 3551 ROGER BROOKE DR | ||||||||
Address2: |   | ||||||||
City: | FORT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 782344504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105399582 | ||||||||
FaxNumber: | 2109165102 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2006 | ||||||||
LastUpdateDate: | 06/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA04884 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 191929201 | 05 | TX |   | MEDICAID | 94829 | 01 | TX | CARELINK | OTHER | 8Y0511 | 01 | TX | BCBS | OTHER |