MEDICARE: W. NOUBANI, PA MEDICAL 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	363AM0700X	Medical Physician Assistant	PA03902	TX

General Provider Information

NPI Number	:	1568691764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W. NOUBANI, PA MEDICAL PLLC

Provider Business Mailing Address
First Line	:	6407 S COOPER ST
Second Line	:	117
City	:	ARLINGTON
State	:	TX
Zip	:	76001-6795
Country	:	US
Telephone Number	:	817-472-7601
Fax Number	:	817-472-7213

Provider Business Practice Location Address
First Line	:	6407 S COOPER ST
Second Line	:	117
City	:	ARLINGTON
State	:	TX
Zip	:	76001-6795
Country	:	US
Telephone Number	:	817-472-7601
Fax Number	:	817-472-7213

Authorized Official
Title or Position	:	OWNER
Name	:	MR. WISSAM NOUBANI
Credential	:
Telephone Number	:	817-472-7601

Provider Enumeration Date	:	07/08/2009
Last Update Date	:	07/08/2009

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