Healthcare Provider Details

I. General information

NPI: 1255472981
Provider Name (Legal Business Name): RADHA DESARAZU CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

11811 FM 1960 RD W SUITE 100
HOUSTON TX
77065-3827
US

IV. Provider business mailing address

PO BOX 841969
DALLAS TX
75284-1969
US

V. Phone/Fax

Practice location:
  • Phone: 281-970-2337
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number578239
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: