Healthcare Provider Details

I. General information

NPI: 1699306746
Provider Name (Legal Business Name): KENNETH JAVIER ZENDEJAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 E IDEL ST
TYLER TX
75701-2024
US

IV. Provider business mailing address

PO BOX 130549
TYLER TX
75713-0549
US

V. Phone/Fax

Practice location:
  • Phone: 903-535-2902
  • Fax: 903-535-9217
Mailing address:
  • Phone: 903-579-3931
  • Fax: 903-509-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP144483
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: