Healthcare Provider Details

I. General information

NPI: 1881134708
Provider Name (Legal Business Name): TU RICCEL CONJE AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 8TH ST
WESLACO TX
78596-6640
US

IV. Provider business mailing address

204 GLASSCOCK
EDINBURG TX
78541-8156
US

V. Phone/Fax

Practice location:
  • Phone: 833-887-4863
  • Fax: 956-296-6857
Mailing address:
  • Phone: 956-330-3176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP133420
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: