Provider Demographics
NPI:1821600487
Name:KURNIAWAN, FRISTANTO (MSN, RN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:FRISTANTO
Middle Name:
Last Name:KURNIAWAN
Suffix:
Gender:M
Credentials:MSN, RN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MEDICAL PLAZA DR STE 250
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-3477
Mailing Address - Country:US
Mailing Address - Phone:281-296-8788
Mailing Address - Fax:
Practice Address - Street 1:9250 PINECROFT DR
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3218
Practice Address - Country:US
Practice Address - Phone:713-897-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1006744363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care