MEDICARE: MR. JOHNY ABRAHAM FNP

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	AP114875	TX

General Provider Information

NPI Number	:	1821413857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHNY ABRAHAM FNP

Provider Business Mailing Address
First Line	:	926 WALNUT ST
Second Line	:
City	:	COLUMBUS
State	:	TX
Zip	:	78934-2215
Country	:	US
Telephone Number	:	979-942-9084
Fax Number	:	718-640-2713

Provider Business Practice Location Address
First Line	:	1249 DEER RIDGE DR
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-5203
Country	:	US
Telephone Number	:	281-332-8163
Fax Number	:

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

Provider Enumeration Date	:	02/27/2014
Last Update Date	:	09/19/2019

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