Provider Demographics
NPI:1942811815
Name:PURI, BIRENDRA
Entity Type:Individual
Prefix:
First Name:BIRENDRA
Middle Name:
Last Name:PURI
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 1:614 W 9 TH ST
Mailing Address - Street 2:
Mailing Address - City:IRAAN
Mailing Address - State:TX
Mailing Address - Zip Code:79744
Mailing Address - Country:US
Mailing Address - Phone:972-804-6465
Mailing Address - Fax:
Practice Address - Street 1:3600 N GARFIELD ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-6329
Practice Address - Country:US
Practice Address - Phone:432-620-1124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
TXPA16120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program