Healthcare Provider Details

I. General information

NPI: 1912156407
Provider Name (Legal Business Name): CHINNAPA R GADE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PENNSYLVANIA AVE
FORT WORTH TX
76104-2228
US

IV. Provider business mailing address

1000 W CANNON ST
FORT WORTH TX
76104-3029
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-5858
  • Fax: 817-335-4418
Mailing address:
  • Phone: 817-725-7900
  • Fax: 682-207-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041368825
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP129918
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: