Provider Demographics
NPI:1194075705
Name:MCDANIEL, MARY PHYLINDA REDEKER (PNP-BC)
Entity type:Individual
Prefix:
First Name:MARY PHYLINDA
Middle Name:REDEKER
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:MARY PHYLINDA
Other - Middle Name:
Other - Last Name:REDEKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP-BC
Mailing Address - Street 1:5738 THUNDER OAKS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261
Mailing Address - Country:US
Mailing Address - Phone:210-737-8555
Mailing Address - Fax:
Practice Address - Street 1:333 N SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX699906363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics