Healthcare Provider Details

I. General information

NPI: 1023051471
Provider Name (Legal Business Name): DIANE WALLACE LANDERS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W INTERSTATE 20 STE 120
ARLINGTON TX
76017-5871
US

IV. Provider business mailing address

811 W INTERSTATE 20 STE 120
ARLINGTON TX
76017-5871
US

V. Phone/Fax

Practice location:
  • Phone: 817-468-3393
  • Fax: 817-468-8734
Mailing address:
  • Phone: 817-468-3393
  • Fax: 817-468-8734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: