Healthcare Provider Details

I. General information

NPI: 1366182503
Provider Name (Legal Business Name): PAOLO ANTONIO MASBAD MORALES AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6411 FANNIN ST
HOUSTON TX
77030-1501
US

IV. Provider business mailing address

6411 FANNIN ST
HOUSTON TX
77030-1501
US

V. Phone/Fax

Practice location:
  • Phone: 713-704-2004
  • Fax:
Mailing address:
  • Phone: 713-704-2004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1073651
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number1073651
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: