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General NPI Number Information
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NPI Number | 1104538651
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Entity Type | Organization
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Legal Business Name | LONESTAR NEPHROLOGY PLLC
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Dates
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Enumeration Date | 12/15/2022
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Last Update Date | 12/15/2022
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Provider Practice Location Address
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Address Line | 2310 DE LEE ST STE 300
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City | BRYAN
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State | TX
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Zip | 77802-2815
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Country | US
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Telephone | 979-485-9401
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6084
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City | BRYAN
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State | TX
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Zip | 77805-6084
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Country | US
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Telephone | 979-485-9401
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PROSPERITY EZEANUNA
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Credential | MD
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Telephone | 979-402-2115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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