Provider Demographics
NPI:1396850871
Name:MACMURDO, LEE M III (FNP)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:M
Last Name:MACMURDO
Suffix:III
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 BEECHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4224
Mailing Address - Country:US
Mailing Address - Phone:432-553-3240
Mailing Address - Fax:
Practice Address - Street 1:410 N HANCOCK AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5140
Practice Address - Country:US
Practice Address - Phone:432-279-0905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX630161363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1751356-01Medicaid
TX175135601Medicaid
TX175135601Medicaid
8E0294Medicare PIN