MEDICARE: ANJAE TARAY HOLDER

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	363LP0200X	Pediatric Nurse Practitioner	1174771	TX

General Provider Information

NPI Number	:	1831905694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANJAE TARAY HOLDER

Provider Business Mailing Address
First Line	:	1101 MIRAMAR AVE
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-4816
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1759 BROAD PARK CIR S STE 201
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-7834
Country	:	US
Telephone Number	:	682-341-3910
Fax Number	:

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

Provider Enumeration Date	:	12/06/2024
Last Update Date	:	12/06/2024

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