MEDICARE: MRS. AUDRINA CATHLEEN BOVAN AGACNP

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	363LA2100X	Acute Care Nurse Practitioner	785666	TX
2	363LG0600X	Gerontology Nurse Practitioner	785666	TX

General Provider Information

NPI Number	:	1730608191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AUDRINA CATHLEEN BOVAN AGACNP

Provider Business Mailing Address
First Line	:	4532 N MESA ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-6286
Country	:	US
Telephone Number	:	915-247-3150
Fax Number	:

Provider Business Practice Location Address
First Line	:	4532 N MESA ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-6286
Country	:	US
Telephone Number	:	915-247-3150
Fax Number	:

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

Provider Enumeration Date	:	09/15/2017
Last Update Date	:	09/15/2017

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