Healthcare Provider Details

I. General information

NPI: 1013050533
Provider Name (Legal Business Name): NICOLE ANN BRAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 WESTERN CENTER BLVD STE 312
FORT WORTH TX
76131-4302
US

IV. Provider business mailing address

2340 E TRINITY MILLS RD STE 250
CARROLLTON TX
75006-1946
US

V. Phone/Fax

Practice location:
  • Phone: 855-893-5637
  • Fax: 817-666-3873
Mailing address:
  • Phone: 972-417-8937
  • Fax: 972-439-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04796
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: