Healthcare Provider Details

I. General information

NPI: 1760148092
Provider Name (Legal Business Name): DUSTIN RYAN TOLAR AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 WINDSOR PL STE 102
FORT WORTH TX
76110-1866
US

IV. Provider business mailing address

1902 WINDSOR PL STE 102
FORT WORTH TX
76110-1866
US

V. Phone/Fax

Practice location:
  • Phone: 682-207-1700
  • Fax: 682-250-5246
Mailing address:
  • Phone: 682-207-1700
  • Fax: 682-250-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1058628
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1058628
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: