Provider Demographics
NPI:1104538651
Name:LONESTAR NEPHROLOGY PLLC
Entity type:Organization
Organization Name:LONESTAR NEPHROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PROSPERITY
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEANUNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-402-2115
Mailing Address - Street 1:PO BOX 6084
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77805-6084
Mailing Address - Country:US
Mailing Address - Phone:979-485-9401
Mailing Address - Fax:
Practice Address - Street 1:2310 DE LEE ST STE 300
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2815
Practice Address - Country:US
Practice Address - Phone:979-485-9401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty