Basic Information
| Provider Information | |||||||||
| NPI: | 1326301946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | BOOTH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2925 BRIARPARK DR STE 575 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770423776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1150 N LOOP 1604 W STE 150 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782484505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817838162 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 745979 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP121943 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.