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General NPI Number Information
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NPI Number | 1982212841
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Entity Type | Individual
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Provider Name | ALEXANDER LEE PENDERGRASS FNP-C
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Gender | Male
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Dates
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Enumeration Date | 07/16/2020
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Last Update Date | 07/16/2020
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Provider Practice Location Address
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Address Line | 808 WOODROW WILSON RAY CIR
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City | BRIDGEPORT
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State | TX
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Zip | 76426-2061
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Country | US
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Telephone | 817-966-2960
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Fax |
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Provider Business Mailing Address
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Address Line | 3250 RIVER LODGE TRL S APT 420
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City | FORT WORTH
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State | TX
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Zip | 76116-0830
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Country | US
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Telephone | 817-966-2960
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1003207
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License Number State | TX
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