Basic Information
Provider Information | |||||||||
NPI: | 1922435858 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITSON | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | SUZANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOBER | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | SUZANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ACNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 848491 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752848491 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2542029330 | ||||||||
FaxNumber: | 2542029349 | ||||||||
Practice Location | |||||||||
Address1: | 100 HILLCREST MEDICAL BLVD | ||||||||
Address2: |   | ||||||||
City: | WACO | ||||||||
State: | TX | ||||||||
PostalCode: | 767128897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2542022000 | ||||||||
FaxNumber: | 2542025651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2013 | ||||||||
LastUpdateDate: | 09/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 562664 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | AP124508 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 329697201 | 05 | TX |   | MEDICAID |