Healthcare Provider Details

I. General information

NPI: 1801567367
Provider Name (Legal Business Name): PAUL BRUCE KUDER III FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date: 09/24/2021
Reactivation Date: 10/20/2021

III. Provider practice location address

4450 SUNSET DR
SAN ANGELO TX
76901-5611
US

IV. Provider business mailing address

4450 SUNSET DR
SAN ANGELO TX
76901-5611
US

V. Phone/Fax

Practice location:
  • Phone: 325-481-2277
  • Fax:
Mailing address:
  • Phone: 325-481-2277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1055512
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: