Healthcare Provider Details

I. General information

NPI: 1396811162
Provider Name (Legal Business Name): JULIO DUARTE SR. LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2006
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20935 SOUTH AMBER WILLOW TRAIL
CYPRESS TX
77433-6041
US

IV. Provider business mailing address

P.O. BOX 1062 20935 SOUTH AMBER WILLOW TRAIL
CYPRESS TX
77410-1062
US

V. Phone/Fax

Practice location:
  • Phone: 281-460-8771
  • Fax: 281-256-9416
Mailing address:
  • Phone: 281-460-8771
  • Fax: 281-256-9416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberSA00118
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00118
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: