Healthcare Provider Details

I. General information

NPI: 1154941227
Provider Name (Legal Business Name): ANGEL ESCOBEDO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2020
Last Update Date: 04/19/2020
Certification Date: 04/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

386 COUNTY ROAD 3886
QUEEN CITY TX
75572-4937
US

V. Phone/Fax

Practice location:
  • Phone: 318-990-4770
  • Fax:
Mailing address:
  • Phone: 805-479-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number950017
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: