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General NPI Number Information
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NPI Number | 1568098937
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Entity Type | Organization
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Legal Business Name | MEDSUR ONE TELEMEDICINE LLC
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Dates
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Enumeration Date | 03/18/2020
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Last Update Date | 03/18/2020
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Provider Practice Location Address
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Address Line | 110 EISENHOWER COURT (ADMINISTRATIVE OFFICE LOCATION) 1309 COFFEEN AVE STE 1200 SHERIDAN WY 82801
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City | GEORGETOWN
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State | TX
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Zip | 78633
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Country | US
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Telephone | 307-655-1666
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Fax | 512-651-4666
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Provider Business Mailing Address
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Address Line | 1309 COFFEEN AVENUE STE 1200
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City | SHERIDAN
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State | WY
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Zip | 82801
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Country | US
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Telephone | 307-655-1666
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Fax | 512-651-4666
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Authorized Official
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Title or Position | MANAGER
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Name | KATHLEEN MCCOY
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Credential | NURSE PRACTITION
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Telephone | 512-364-2151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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