Basic Information
| Provider Information | |||||||||
| NPI: | 1275533663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIDAL-KUTIN | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | |||||||||
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| Credential: | WHCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 523 S FANNIN AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035359041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 928 N GLENWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757025055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035359041 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 597340 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | AP107251 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 042516705 | 05 | TX | MEDICAID | 042516708 | 05 | TX | MEDICAID | 042516710 | 05 | TX | MEDICAID | 042516704 | 05 | TX | MEDICAID | 042516711 | 05 | TX | MEDICAID | 45-2578435-002 | 01 | TX | TRICARE | OTHER | 042516702 | 05 | TX | MEDICAID | 042516707 | 05 | TX | MEDICAID | 042516713 | 05 | TX | MEDICAID | 042516706 | 05 | TX | MEDICAID | 042516709 | 05 | TX | MEDICAID | 042516715 | 05 | TX | MEDICAID | 8971NK | 01 | TX | BCBS | OTHER | 0021YB | 01 | TX | BCBS | OTHER | 042516703 | 05 | TX | MEDICAID | 042516712 | 05 | TX | MEDICAID | 45-2578435-001 | 01 | TX | TICARE | OTHER | 452578435001 | 01 | TX | TRICARE | OTHER | 857919 | 01 | TX | MEDICARE | OTHER | 042516714 | 05 | TX | MEDICAID | 8LV009 | 01 | TX | BCBS | OTHER | 8N4773 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |