MEDICARE: FUSION WOMEN'S HEALTH AND WELLNESS, PLLC

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	207V00000X	Obstetrics & Gynecology Physician	34-007697	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548537038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUSION WOMEN'S HEALTH AND WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 164698
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76161-4698
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7250 HAWKINS VIEW DR
Second Line	:	SUITE 411
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3920
Country	:	US
Telephone Number	:	806-468-4317
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/PHYSICIAN
Name	:	DR. LISA L GARDNER
Credential	:	D.O.
Telephone Number	:	806-468-4317

Provider Enumeration Date	:	11/28/2011
Last Update Date	:	04/12/2012

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