Provider Demographics
NPI:1063465409
Name:WILLEFORD, CARL AUSTIN JR (FNP-C)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:AUSTIN
Last Name:WILLEFORD
Suffix:JR
Gender:M
Credentials:FNP-C
Other - Prefix:
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Mailing Address - Street 1:2702 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2922
Mailing Address - Country:US
Mailing Address - Phone:936-221-5138
Mailing Address - Fax:936-221-5150
Practice Address - Street 1:2702 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2922
Practice Address - Country:US
Practice Address - Phone:936-221-5138
Practice Address - Fax:936-221-5150
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXAP114322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J0615Medicare PIN