Provider Demographics
NPI:1497330542
Name:KONWISARZ, CAITLIN MARIE (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:KONWISARZ
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25115 LAKECREST GLEN DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-4017
Mailing Address - Country:US
Mailing Address - Phone:512-785-2520
Mailing Address - Fax:
Practice Address - Street 1:1635 NORTH LOOP W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1532
Practice Address - Country:US
Practice Address - Phone:713-867-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1031921363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine