=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790357937
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL AYDALLA AGACNP-BC, MSN, RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2021
-----------------------------------------------------
Last Update Date | 04/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5501 US-77
-----------------------------------------------------
City | HARLINGEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-365-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 COLORADO AVE APT 208
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-5539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-960-3691
-----------------------------------------------------
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 | 1045274
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 1045274
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 1045274
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1045274
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------