Basic Information
Provider Information | |||||||||
NPI: | 1578815783 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALONSO | ||||||||
FirstName: | MARY LOU | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 222 LAS COLINAS BLVD W | ||||||||
Address2: | SUITE 2000 | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 750395421 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729573000 | ||||||||
FaxNumber: | 8323803985 | ||||||||
Practice Location | |||||||||
Address1: | 25647 REDWOOD HWY | ||||||||
Address2: |   | ||||||||
City: | CAVE JUNCTION | ||||||||
State: | OR | ||||||||
PostalCode: | 975239332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415924111 | ||||||||
FaxNumber: | 5415923916 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2012 | ||||||||
LastUpdateDate: | 10/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 95009439 | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 721070 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 202002885NP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.