Healthcare Provider Details

I. General information

NPI: 1285727941
Provider Name (Legal Business Name): WISSAM NOUBANI P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4504 BOAT CLUB RD SUITE 800
FORT WORTH TX
76135-7003
US

IV. Provider business mailing address

4504 BOAT CLUB RD SUITE 800
FORT WORTH TX
76135-7003
US

V. Phone/Fax

Practice location:
  • Phone: 817-237-0515
  • Fax: 817-237-8982
Mailing address:
  • Phone: 817-237-4794
  • Fax: 817-237-4880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03902
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: