Healthcare Provider Details

I. General information

NPI: 1124948930
Provider Name (Legal Business Name): MICAH HORTILLOSA HOSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 WELLESLEY DR
CONROE TX
77304-1331
US

IV. Provider business mailing address

3 WELLESLEY DR
CONROE TX
77304-1331
US

V. Phone/Fax

Practice location:
  • Phone: 713-515-2507
  • Fax:
Mailing address:
  • Phone: 713-515-2507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1243668
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: