Provider Demographics
NPI:1780347641
Name:JUSTICE, CODY RYAN (RN)
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:RYAN
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3017 WEAVE CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-1280
Mailing Address - Country:US
Mailing Address - Phone:817-454-7151
Mailing Address - Fax:
Practice Address - Street 1:1600 11TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4300
Practice Address - Country:US
Practice Address - Phone:940-764-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX893913163W00000X
TX1066724367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1780347641Medicaid