MEDICARE: MRS. DANIELLA G HALL 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	363A00000X	Physician Assistant	PA 06164	TX

General Provider Information

NPI Number	:	1396075594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANIELLA G HALL PA-C

Provider Business Mailing Address
First Line	:	2100 N MAIN ST.
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 N MAIN ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-8570
Country	:	US
Telephone Number	:	817-625-4254
Fax Number	:

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

Provider Enumeration Date	:	01/11/2010
Last Update Date	:	05/31/2012

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