Provider Demographics
NPI:1982137915
Name:LIN, CHARISSE BANAWIS (FNP)
Entity type:Individual
Prefix:
First Name:CHARISSE
Middle Name:BANAWIS
Last Name:LIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13520 OREGON FLATS TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6363
Mailing Address - Country:US
Mailing Address - Phone:512-450-4345
Mailing Address - Fax:
Practice Address - Street 1:940 W UNIVERSITY AVE STE 105
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5430
Practice Address - Country:US
Practice Address - Phone:512-763-5149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX369241001Medicaid