Provider Demographics
NPI:1205214673
Name:SUPERVILLE, CARIS (AGPCNP)
Entity Type:Individual
Prefix:
First Name:CARIS
Middle Name:
Last Name:SUPERVILLE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3967 FERNANDO DR
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3448
Mailing Address - Country:US
Mailing Address - Phone:940-632-6843
Mailing Address - Fax:
Practice Address - Street 1:7610 W HIGHWAY 71
Practice Address - Street 2:SUITE F
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8231
Practice Address - Country:US
Practice Address - Phone:512-288-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127762363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology