Provider Demographics
NPI:1326548108
Name:BACALLAO RODRIGUEZ, DIOSDANY ROBERTO (RN, APRN-CNP)
Entity Type:Individual
Prefix:
First Name:DIOSDANY
Middle Name:ROBERTO
Last Name:BACALLAO RODRIGUEZ
Suffix:
Gender:M
Credentials:RN, APRN-CNP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:15603 WINDING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-2747
Mailing Address - Country:US
Mailing Address - Phone:832-830-4567
Mailing Address - Fax:
Practice Address - Street 1:15603 WINDING VALLEY DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-2747
Practice Address - Country:US
Practice Address - Phone:832-830-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX919984163W00000X
TX1129701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse