MEDICARE: MS. JACKIE LYNNE FLUHARTY 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	PA04480	TX

General Provider Information

NPI Number	:	1487791562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACKIE LYNNE FLUHARTY PA-C

Provider Business Mailing Address
First Line	:	3513 RIVERSTONE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-0699
Country	:	US
Telephone Number	:	915-269-5571
Fax Number	:

Provider Business Practice Location Address
First Line	:	2487 RICKER ROAD
Second Line	:	WBAMC
City	:	FT BLISS
State	:	TX
Zip	:	79916
Country	:	US
Telephone Number	:	915-569-4387
Fax Number	:

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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