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NPI Code Detail

MEDICARE: IMANI ISSA

MEDICARE: IMANI ISSA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1245713569
Entity Type Code : Individual
Provider Name (Legal Business Name) : IMANI ISSA
Provider Business Mailing Address
First Line : 2366 STAGECOACH ST
Second Line :
City : FORT WORTH
State : TX
Zip : 76133-8196
Country : US
Telephone Number : 817-707-4208
Fax Number :
Provider Business Practice Location Address
First Line : 3900 UNIVERSITY BLVD
Second Line :
City : TYLER
State : TX
Zip : 75799-6600
Country : US
Telephone Number : 817-707-4208
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/12/2018
Last Update Date : 09/12/2018

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Directions to “ IMANI ISSA ” Practice Location

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