Basic Information
| Provider Information | |||||||||
| NPI: | 1750367314 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEAN GISLER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CROSSROADS FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779033276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615763680 | ||||||||
| FaxNumber: | 3615764219 | ||||||||
| Practice Location | |||||||||
| Address1: | 3002 SAM HOUSTON DR | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779042682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615754100 | ||||||||
| FaxNumber: | 3615754111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GISLER | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3615754100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 427272 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0024LH | 01 | TX | BCBS OF TX # | OTHER | 167309702 | 05 | TX | MEDICAID |