Provider Demographics
NPI:1104245984
Name:STEPHAN, PUNNAM (FNP-C)
Entity type:Individual
Prefix:
First Name:PUNNAM
Middle Name:
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 SWISS AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6251
Mailing Address - Country:US
Mailing Address - Phone:214-828-5050
Mailing Address - Fax:
Practice Address - Street 1:3434 SWISS AVE
Practice Address - Street 2:STE 310
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6251
Practice Address - Country:US
Practice Address - Phone:214-828-5050
Practice Address - Fax:214-828-5051
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX694378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3401879-04Medicaid
TX3401879-04Medicaid