Provider Demographics
NPI:1710430509
Name:INNOVATIVE APN LLC
Entity Type:Organization
Organization Name:INNOVATIVE APN LLC
Other - Org Name:KENNETH TAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:512-291-8076
Mailing Address - Street 1:9301 ELM GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78736-7716
Mailing Address - Country:US
Mailing Address - Phone:512-291-8076
Mailing Address - Fax:512-590-7104
Practice Address - Street 1:9301 ELM GROVE CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78736-7716
Practice Address - Country:US
Practice Address - Phone:512-291-8076
Practice Address - Fax:512-590-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118688363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty