Basic Information
| Provider Information | |||||||||
| NPI: | 1992223085 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 2017 FWUC MEDICAL PROFESSIONALS PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 920 S KIMBALL AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760929016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175273403 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 601 NORTHWEST PKWY STE C | ||||||||
| Address2: | |||||||||
| City: | AZLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760202930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172700777 | ||||||||
| FaxNumber: | 8174210036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NEIMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | BRAXTON | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 8174210034 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.