Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | AP140592 | TX |
N | 363LP2300X | Nurse Practitioner - Primary Care | AP140592 | TX |
NPI | 1073079216 |
---|---|
Provider Name | Pete C Bravo JR. |
First Address | Downers Grove, IL 60515-1069 |
Second Address | Southlake, TX 76092-8017 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2019 |
Last Update Date | 13/01/2020 |