Healthcare Provider Details

I. General information

NPI: 1588053409
Provider Name (Legal Business Name): JOHNATAN MARIANO ANP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 01/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ROBBIE MINCE WAY
DESOTO TX
75115-2012
US

IV. Provider business mailing address

8479 DAVIS BLVD STE 100
NORTH RICHLAND HILLS TX
76182-8604
US

V. Phone/Fax

Practice location:
  • Phone: 972-709-7190
  • Fax: 214-941-1765
Mailing address:
  • Phone: 817-953-8450
  • Fax: 844-643-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP126703
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: