Provider Demographics
NPI:1063465409
Name:WILLEFORD, CARL AUSTIN JR (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:AUSTIN
Last Name:WILLEFORD
Suffix:JR
Gender:M
Credentials:FNP-C
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Other - Credentials:
Mailing Address - Street 1:PO BOX 94670
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-4670
Mailing Address - Country:US
Mailing Address - Phone:405-682-3303
Mailing Address - Fax:405-384-6793
Practice Address - Street 1:1018 N MOUND ST STE 203
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4434
Practice Address - Country:US
Practice Address - Phone:936-569-4150
Practice Address - Fax:936-569-4155
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX631071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J0615Medicare PIN