Provider Demographics
NPI:1407491541
Name:LANDOR, DWIGHT W (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:W
Last Name:LANDOR
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:MR
Other - First Name:DWIGHT
Other - Middle Name:W
Other - Last Name:LANDOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:815 BRANDYWINE ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-5425
Mailing Address - Country:US
Mailing Address - Phone:409-422-3714
Mailing Address - Fax:
Practice Address - Street 1:815 BRANDYWINE ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5425
Practice Address - Country:US
Practice Address - Phone:409-422-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2019045415363LF0000X
TXAP143998363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP143998OtherTEXAS BOARD OF NURING