Basic Information
| Provider Information | |||||||||
| NPI: | 1821600487 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KURNIAWAN | ||||||||
| FirstName: | FRISTANTO | ||||||||
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| Credential: | MSN, RN, AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 MEDICAL PLAZA DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773803477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812968788 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9250 PINECROFT DR | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773803218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138972300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2020 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 1006744 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.