=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811480668
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TOMMY WEESNER JR. NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2018
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9301 N CENTRAL EXPY
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75231-0806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-365-8150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 234 W CAMPBELL RD
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-474-3221
-----------------------------------------------------
Fax | 512-782-9316
-----------------------------------------------------
=====================================================
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 | 755993
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------