Healthcare Provider Details

I. General information

NPI: 1336572494
Provider Name (Legal Business Name): TAMMARA J VERDUIN CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 WORTH ST SUITE 630
DALLAS TX
75246-2029
US

IV. Provider business mailing address

PO BOX 141374
DALLAS TX
75214-1374
US

V. Phone/Fax

Practice location:
  • Phone: 214-827-8407
  • Fax:
Mailing address:
  • Phone: 214-522-0210
  • Fax: 214-522-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number036120
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: