Basic Information
Provider Information | |||||||||
NPI: | 1457523284 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUBIN | ||||||||
FirstName: | NORMAN | ||||||||
MiddleName: | ZACHARY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 E UNIVERSITY AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786266814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128681124 | ||||||||
FaxNumber: | 5128689894 | ||||||||
Practice Location | |||||||||
Address1: | 2423 WILLIAMS DR | ||||||||
Address2: | SUITE 108 | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786283200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8778005722 | ||||||||
FaxNumber: | 5128698424 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2008 | ||||||||
LastUpdateDate: | 02/23/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 3005795 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP123171 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163W00000X | 435970 | TX | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 1104521 | KY | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 30610026 | 05 | KY |   | MEDICAID | AP123171 | 01 | TX | LICENSE | OTHER | 3317273-02 | 05 | TX |   | MEDICAID |