Healthcare Provider Details

I. General information

NPI: 1982382198
Provider Name (Legal Business Name): DAVID WAITS BLACKSHEAR NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/07/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 RESEARCH FOREST DR STE 360
THE WOODLANDS TX
77382-1559
US

IV. Provider business mailing address

230 MARTIN CREEK DR
CLEVELAND TX
77328-5641
US

V. Phone/Fax

Practice location:
  • Phone: 281-292-1191
  • Fax:
Mailing address:
  • Phone: 936-283-0436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1127862
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: