MEDICARE: GERSHWIN BONIAO CRUZABRA FNP-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	363L00000X	Nurse Practitioner	1193622	TX

General Provider Information

NPI Number	:	1689472706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERSHWIN BONIAO CRUZABRA FNP-C

Provider Business Mailing Address
First Line	:	164 BELTERRA VILLAGE WAY STE X200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78737-4794
Country	:	US
Telephone Number	:	512-596-0595
Fax Number	:

Provider Business Practice Location Address
First Line	:	164 BELTERRA VILLAGE WAY STE X200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78737-4794
Country	:	US
Telephone Number	:	512-596-0595
Fax Number	:

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

Provider Enumeration Date	:	03/04/2025
Last Update Date	:	06/08/2026

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