Provider Demographics
NPI:1700417011
Name:CALVILLO, GUSTAVO JR (APRN-CNP)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:CALVILLO
Suffix:JR
Gender:M
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:GUS
Other - Middle Name:
Other - Last Name:CALVILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN-CNP
Mailing Address - Street 1:1123 BROADWAY ST STE B
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77012-3711
Mailing Address - Country:US
Mailing Address - Phone:832-538-0974
Mailing Address - Fax:
Practice Address - Street 1:1123 BROADWAY ST STE B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77012-3711
Practice Address - Country:US
Practice Address - Phone:832-538-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1019340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily