Basic Information
| Provider Information | |||||||||
| NPI: | 1639793730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DVORAK | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4351 BOOTH CALLOWAY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761807398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172841165 | ||||||||
| FaxNumber: | 8172844990 | ||||||||
| Practice Location | |||||||||
| Address1: | 4351 BOOTH CALLOWAY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761807398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172841165 | ||||||||
| FaxNumber: | 8172844990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2020 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 230697 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 230697 | 01 | TX | NURSE LICENSE | OTHER |