Basic Information
| Provider Information | |||||||||
| NPI: | 1275169724 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | BINCY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATHEW | ||||||||
| OtherFirstName: | BINCY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 122 W JOHN CARPENTER FWY STE 420 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750392014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729573000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4200 SOUTH FWY STE 106 FORT WORTH TX 76115 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175660505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2020 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP145454 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WE0003X | 774689 | TX | N | Nursing Service Providers | Registered Nurse | Emergency |
ID Information
| ID | Type | State | Issuer | Description | AP145454 | 01 | TX | APRN | OTHER | 774689 | 01 | TX | REGISTERED NURSE | OTHER |