Provider Demographics
NPI:1588053409
Name:MARIANO, JOHNATAN (ANP)
Entity type:Individual
Prefix:
First Name:JOHNATAN
Middle Name:
Last Name:MARIANO
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8479 DAVIS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-8604
Mailing Address - Country:US
Mailing Address - Phone:817-953-8450
Mailing Address - Fax:844-643-2362
Practice Address - Street 1:1001 ROBBIE MINCE WAY
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2012
Practice Address - Country:US
Practice Address - Phone:972-709-7190
Practice Address - Fax:214-941-1765
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126703363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health