1801067103 NPI number — MS. DANA ELAINE MAXEY PA

Table of content: MS. DANA ELAINE MAXEY PA (NPI 1801067103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801067103 NPI number — MS. DANA ELAINE MAXEY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAXEY
Provider First Name:
DANA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801067103
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 610393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75261-0393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-291-6187
Provider Business Mailing Address Fax Number:
903-237-1810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75605-5128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-757-6042
Provider Business Practice Location Address Fax Number:
903-232-8187
Provider Enumeration Date:
03/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA05610 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 211973705 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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