Provider Demographics
NPI:1912433707
Name:RONQUILLO, MAURA RUBY
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:RUBY
Last Name:RONQUILLO
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 1:1301 W 38TH ST
Mailing Address - Street 2:SUITE 705
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1000
Mailing Address - Country:US
Mailing Address - Phone:575-650-6415
Mailing Address - Fax:
Practice Address - Street 1:1301 W 38TH ST
Practice Address - Street 2:SUITE 705
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1000
Practice Address - Country:US
Practice Address - Phone:575-650-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM506718538207V00000X
TXT0612207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10059760OtherBASIC POST GRADUATE TRAINING PERMIT