Provider Demographics
NPI:1285727941
Name:NOUBANI, WISSAM (PA-C)
Entity type:Individual
Prefix:
First Name:WISSAM
Middle Name:
Last Name:NOUBANI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 BOAT CLUB RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7003
Mailing Address - Country:US
Mailing Address - Phone:817-237-4794
Mailing Address - Fax:817-237-4880
Practice Address - Street 1:4504 BOAT CLUB RD
Practice Address - Street 2:SUITE 800
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7003
Practice Address - Country:US
Practice Address - Phone:817-237-0515
Practice Address - Fax:817-237-8982
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS74081Medicare UPIN
TX8B7143Medicare ID - Type Unspecified