=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588075402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN BULLARD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2014
-----------------------------------------------------
Last Update Date | 02/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 MARSHA SHARP FWY
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79407-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-744-7223
-----------------------------------------------------
Fax | 806-740-3325
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 FM 300
-----------------------------------------------------
City | LEVELLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79336-6235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-894-7842
-----------------------------------------------------
Fax | 806-894-3378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP125507
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------