Healthcare Provider Details

I. General information

NPI: 1043734882
Provider Name (Legal Business Name): MICHAEL LEON GAINES FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N VIRGINIA ST FL 2
PORT LAVACA TX
77979-3025
US

IV. Provider business mailing address

220 BONHAM ST
PORT LAVACA TX
77979-2605
US

V. Phone/Fax

Practice location:
  • Phone: 361-552-0379
  • Fax: 361-500-6904
Mailing address:
  • Phone: 361-935-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP134737
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: