Healthcare Provider Details

I. General information

NPI: 1750563748
Provider Name (Legal Business Name): EGRET BAY NEUROLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18333 EGRET BAY BLVD SUITE 650
HOUSTON TX
77058-3860
US

IV. Provider business mailing address

18333 EGRET BAY BLVD SUITE 650
HOUSTON TX
77058-3860
US

V. Phone/Fax

Practice location:
  • Phone: 281-333-9933
  • Fax: 281-333-4072
Mailing address:
  • Phone: 281-333-9933
  • Fax: 281-333-4072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number554544
License Number StateTX

VIII. Authorized Official

Name: MAVIS D FUJII
Title or Position: PRESIDENT
Credential: MD
Phone: 281-333-9933