Provider Demographics
NPI:1588247639
Name:RICKERSON, STEPHANIE MARIANA
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIANA
Last Name:RICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MARIANA
Other - Last Name:RICHTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1806 SUMMERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2337
Mailing Address - Country:US
Mailing Address - Phone:713-505-2893
Mailing Address - Fax:
Practice Address - Street 1:5825 CALLAGHAN RD STE 203
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1107
Practice Address - Country:US
Practice Address - Phone:210-341-9614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15568363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical