1811366545 NPI number — STEVEN MICHAEL PRUDENCIO FNP

Table of content: STEVEN MICHAEL PRUDENCIO FNP (NPI 1811366545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811366545 NPI number — STEVEN MICHAEL PRUDENCIO FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUDENCIO
Provider First Name:
STEVEN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811366545
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2129
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79760-2129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-640-1963
Provider Business Mailing Address Fax Number:
432-640-1875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 GOLDER AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-5043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-640-1963
Provider Business Practice Location Address Fax Number:
432-640-1875
Provider Enumeration Date:
09/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP128729 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com