MEDICARE: MISTY DAWN TATOM ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	894413	TX
2	363LF0000X	Family Nurse Practitioner	AP61530730	WA
3	363LF0000X	Family Nurse Practitioner	1108433	TX

General Provider Information

NPI Number	:	1134832074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY DAWN TATOM ARNP

Provider Business Mailing Address
First Line	:	1507 W LEAGUE CITY PKWY
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-7339
Country	:	US
Telephone Number	:	713-737-5219
Fax Number	:

Provider Business Practice Location Address
First Line	:	1507 W LEAGUE CITY PKWY
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-7339
Country	:	US
Telephone Number	:	713-737-5219
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2023
Last Update Date	:	06/24/2024

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