MEDICARE: EDGE-MD LAKE JUNE, PLLC

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
1	207Q00000X	Family Medicine Physician	N0318	TX

General Provider Information

NPI Number	:	1720488745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGE-MD LAKE JUNE, PLLC

Provider Business Mailing Address
First Line	:	2022 REGIONAL MEDICAL DR
Second Line	:	SUITE 1315
City	:	WHARTON
State	:	TX
Zip	:	77488-7231
Country	:	US
Telephone Number	:	979-532-2000
Fax Number	:	979-532-2008

Provider Business Practice Location Address
First Line	:	6909 LAKE JUNE RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217-1325
Country	:	US
Telephone Number	:	214-391-1900
Fax Number	:	214-391-1914

Authorized Official
Title or Position	:	OWNER/MD
Name	:	DR. NATHAN P. NGUYEN
Credential	:	MD
Telephone Number	:	979-532-2000

Provider Enumeration Date	:	08/27/2014
Last Update Date	:	01/13/2015

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