Provider Demographics
NPI:1811549421
Name:MBURU, GEORGE
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:MBURU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 SPRINGTREE ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76209-6532
Mailing Address - Country:US
Mailing Address - Phone:845-702-6538
Mailing Address - Fax:
Practice Address - Street 1:2001 S MEDFORD DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-6260
Practice Address - Country:US
Practice Address - Phone:936-633-5632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX841742163WP0808X
TXAP142454363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health