Healthcare Provider Details

I. General information

NPI: 1689472706
Provider Name (Legal Business Name): GERSHWIN BONIAO CRUZABRA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 ELMHURST STE 100
KYLE TX
78640-6060
US

IV. Provider business mailing address

408 W 45TH ST
AUSTIN TX
78751-3014
US

V. Phone/Fax

Practice location:
  • Phone: 512-268-3100
  • Fax:
Mailing address:
  • Phone: 512-451-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1193622
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: