Healthcare Provider Details

I. General information

NPI: 1821427790
Provider Name (Legal Business Name): NATHANIEL NEAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 NORTH FWY
FORT WORTH TX
76137-2481
US

IV. Provider business mailing address

PO BOX 9101 STE 600
COPPELL TX
75019-9494
US

V. Phone/Fax

Practice location:
  • Phone: 817-439-8100
  • Fax: 817-439-8103
Mailing address:
  • Phone: 972-745-7500
  • Fax: 972-471-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA08634
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: