Healthcare Provider Details

I. General information

NPI: 1245877000
Provider Name (Legal Business Name): STEPHEN RAY HALBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2019
Last Update Date: 12/07/2019
Certification Date: 12/07/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 INDIANA AVE STE 540
WICHITA FALLS TX
76301-6734
US

IV. Provider business mailing address

1503 KINTA TRL
WICHITA FALLS TX
76310-8165
US

V. Phone/Fax

Practice location:
  • Phone: 940-249-5253
  • Fax:
Mailing address:
  • Phone: 940-782-6626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP144219
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: