Provider Demographics
NPI:1083662787
Name:BUNCH, AZALEA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:AZALEA
Middle Name:MARIE
Last Name:BUNCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 MAIN ST
Mailing Address - Street 2:SUITE 5200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4612
Mailing Address - Country:US
Mailing Address - Phone:214-712-2448
Mailing Address - Fax:214-712-2487
Practice Address - Street 1:605 HOLDERRIETH BLVD
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-6445
Practice Address - Country:US
Practice Address - Phone:281-401-7695
Practice Address - Fax:281-401-7883
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX693984363L00000X
TXAP114189363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y0144OtherBCBSTX PROVIDER NUMBER
TX8Y3484OtherBCBS
TXQ52778Medicare UPIN
TX8J1264Medicare PIN
TX8Y0144OtherBCBSTX PROVIDER NUMBER