MEDICARE: GRAYSON TABOR RN

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	1146462	TX

General Provider Information

NPI Number	:	1679499719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRAYSON TABOR RN

Provider Business Mailing Address
First Line	:	8203 GRIMCHESTER
Second Line	:
City	:	CONVERSE
State	:	TX
Zip	:	78109-3231
Country	:	US
Telephone Number	:	281-620-0505
Fax Number	:

Provider Business Practice Location Address
First Line	:	7909 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3425
Country	:	US
Telephone Number	:	210-437-0884
Fax Number	:

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

Provider Enumeration Date	:	06/24/2026
Last Update Date	:	06/24/2026

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