Provider Demographics
NPI:1467844795
Name:FAN, MARY KATE (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATE
Last Name:FAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10004 JOHNS ROAD
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-8811
Mailing Address - Country:US
Mailing Address - Phone:830-267-4575
Mailing Address - Fax:
Practice Address - Street 1:1860 S SEGUIN AVE BLDG E
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-3914
Practice Address - Country:US
Practice Address - Phone:210-232-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126803363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health