Healthcare Provider Details

I. General information

NPI: 1336734409
Provider Name (Legal Business Name): SIBU KURIAKOSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3136 HORIZON RD STE 100
ROCKWALL TX
75032-7808
US

IV. Provider business mailing address

3136 HORIZON RD STE 100
ROCKWALL TX
75032-7808
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14258
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA14258
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: