MEDICARE: WISSAM NOUBANI P.A.-C

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	363A00000X	Physician Assistant	PA03902	TX

General Provider Information

NPI Number	:	1285727941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WISSAM NOUBANI P.A.-C

Provider Business Mailing Address
First Line	:	4504 BOAT CLUB RD
Second Line	:	SUITE 800
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7003
Country	:	US
Telephone Number	:	817-237-4794
Fax Number	:	817-237-4880

Provider Business Practice Location Address
First Line	:	4504 BOAT CLUB RD
Second Line	:	SUITE 800
City	:	FORT WORTH
State	:	TX
Zip	:	76135-7003
Country	:	US
Telephone Number	:	817-237-0515
Fax Number	:	817-237-8982

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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