Provider Demographics
NPI:1003091356
Name:KATY PEDIATRIC ASSOCIATES
Entity type:Organization
Organization Name:KATY PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:281-492-7676
Mailing Address - Street 1:2051 GREENHOUSE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-7305
Mailing Address - Country:US
Mailing Address - Phone:281-492-7676
Mailing Address - Fax:281-492-8133
Practice Address - Street 1:2051 GREENHOUSE RD STE 120
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-7305
Practice Address - Country:US
Practice Address - Phone:281-492-7676
Practice Address - Fax:281-492-8133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0016KBOtherBLUE BLUE SHIELD OF TEXAS
TX121010602Medicaid