Healthcare Provider Details

I. General information

NPI: 1568691764
Provider Name (Legal Business Name): W. NOUBANI, PA MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6407 S COOPER ST 117
ARLINGTON TX
76001-6795
US

IV. Provider business mailing address

6407 S COOPER ST 117
ARLINGTON TX
76001-6795
US

V. Phone/Fax

Practice location:
  • Phone: 817-472-7601
  • Fax: 817-472-7213
Mailing address:
  • Phone: 817-472-7601
  • Fax: 817-472-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA03902
License Number StateTX

VIII. Authorized Official

Name: MR. WISSAM NOUBANI
Title or Position: OWNER
Credential:
Phone: 817-472-7601