Basic Information
Provider Information
NPI: 1003000738
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ZUMWALT
FirstName: JULIETTE
MiddleName: A.
NamePrefix:  
NameSuffix:  
Credential: P.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7401 S. MAIN
Address2:  
City: HOUSTON
State: TX
PostalCode: 77030
CountryCode: US
TelephoneNumber: 7137992300
FaxNumber: 7137943380
Practice Location
Address1: 7401 S. MAIN
Address2:  
City: HOUSTON
State: TX
PostalCode: 770304509
CountryCode: US
TelephoneNumber: 7137992300
FaxNumber: 7137943380
Other Information
ProviderEnumerationDate: 09/06/2007
LastUpdateDate: 08/11/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XPA05374TXY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

ID Information
IDTypeStateIssuerDescription
8Y279401TXBCBSOTHER
19157610105TX MEDICAID


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