MEDICARE: INNOVATIVE APN LLC

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	363LF0000X	Family Nurse Practitioner	AP118688	TX

General Provider Information

NPI Number	:	1710430509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE APN LLC

Provider Business Mailing Address
First Line	:	9301 ELM GROVE CIR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78736-7716
Country	:	US
Telephone Number	:	512-291-8076
Fax Number	:	512-590-7104

Provider Business Practice Location Address
First Line	:	9301 ELM GROVE CIR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78736-7716
Country	:	US
Telephone Number	:	512-291-8076
Fax Number	:	512-590-7104

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MR. KENNETH TAM
Credential	:	NP-C
Telephone Number	:	512-291-8076

Provider Enumeration Date	:	07/27/2016
Last Update Date	:	07/28/2016

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