Healthcare Provider Details

I. General information

NPI: 1689214637
Provider Name (Legal Business Name): JUSTIN WADE FARRAR FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E BYPASS 287
ALVORD TX
76225-7778
US

IV. Provider business mailing address

139 CREEKWOOD RANCH RD
AZLE TX
76020-8045
US

V. Phone/Fax

Practice location:
  • Phone: 940-427-2858
  • Fax:
Mailing address:
  • Phone: 817-239-4104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP144494
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: