=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285413922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARC PROVENZANO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2023
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 493 N MAIN ST
-----------------------------------------------------
City | GROVETON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75845-2498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-515-8349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 395
-----------------------------------------------------
City | GROVETON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75845-0395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 1119122
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------