Provider Demographics
NPI:1427603869
Name:KUNJUKUNJUKUTTYTHARAKAN, TIJU (NP)
Entity Type:Individual
Prefix:
First Name:TIJU
Middle Name:
Last Name:KUNJUKUNJUKUTTYTHARAKAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 RUTHERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-5927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6901 SNIDER PLZ STE 130
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-5649
Practice Address - Country:US
Practice Address - Phone:888-212-4243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142477363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily