Provider Demographics
NPI:1730450578
Name:BOBODZHANOVA, SURAYYO (FNP-C)
Entity type:Individual
Prefix:
First Name:SURAYYO
Middle Name:
Last Name:BOBODZHANOVA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SURAYYO
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN
Mailing Address - Street 1:7323 MARBACH RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1905
Mailing Address - Country:US
Mailing Address - Phone:210-231-2450
Mailing Address - Fax:210-231-2557
Practice Address - Street 1:7323 MARBACH RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1905
Practice Address - Country:US
Practice Address - Phone:210-674-0257
Practice Address - Fax:210-369-9064
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA789243163W00000X
TXAP145912363LF0000X
NE69496163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1730450578OtherINDIVIDUAL NPI
TX0925166-01OtherTRADITIONAL MEDICAID GRP
TX092566-02OtherMEDICAID EPSDT
TXAP145912OtherCERTIFIED NP LICENSE
TX1508813494OtherGROUP PRACTICE NPI
TX988977OtherREGISTERED NURSE LICENSE