=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285033142
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARU LUIS GONZALES LADILAD FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2014
-----------------------------------------------------
Last Update Date | 08/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 PAREDES LINE RD
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78521-2482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-541-9499
-----------------------------------------------------
Fax | 956-541-1321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 PAREDES LINE RD
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78521-2482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-541-9499
-----------------------------------------------------
Fax | 956-541-1321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Nurse Practitioner
-----------------------------------------------------
License Number | AP125956
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP125956
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | AP125956
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------