Provider Demographics
NPI:1114657418
Name:SUDBECK, JUSTIN DANIEL (APRN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DANIEL
Last Name:SUDBECK
Suffix:
Gender:M
Credentials:APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 N KNOWLES DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:TX
Mailing Address - Zip Code:76179-1024
Mailing Address - Country:US
Mailing Address - Phone:682-208-0984
Mailing Address - Fax:
Practice Address - Street 1:1866 KELLER PKWY STE B
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3763
Practice Address - Country:US
Practice Address - Phone:682-337-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1084140363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care