Provider Demographics
NPI:1104348903
Name:JOSE, NIDISH (AGNP-C)
Entity type:Individual
Prefix:
First Name:NIDISH
Middle Name:
Last Name:JOSE
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3044 HIDDEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-2716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3044 HIDDEN VALLEY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-2716
Practice Address - Country:US
Practice Address - Phone:469-844-7072
Practice Address - Fax:817-697-4580
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX789098363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health