Healthcare Provider Details

I. General information

NPI: 1578544631
Provider Name (Legal Business Name): JONATHAN R. DEVANE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 HOSPITAL PKWY STE. 210
BEDFORD TX
76022-5934
US

IV. Provider business mailing address

1451 E HICKORY HILL RD
ARGYLE TX
76226-2919
US

V. Phone/Fax

Practice location:
  • Phone: 817-540-3121
  • Fax: 817-355-4511
Mailing address:
  • Phone: 940-464-4183
  • Fax: 817-355-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04500
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: