MEDICARE: MRS. CAMILLE MARIE SMALL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA11750	TX

General Provider Information

NPI Number	:	1205335858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAMILLE MARIE SMALL PA-C

Provider Business Mailing Address
First Line	:	400 W LBJ FWY STE 330
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-3717
Country	:	US
Telephone Number	:	972-556-2885
Fax Number	:	972-506-8733

Provider Business Practice Location Address
First Line	:	400 W LBJ FWY STE 330
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-3717
Country	:	US
Telephone Number	:	972-556-2885
Fax Number	:	972-506-8733

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2018
Last Update Date	:	02/09/2018

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