Healthcare Provider Details

I. General information

NPI: 1437297645
Provider Name (Legal Business Name): LARRY JAMES IRWIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN
DALLAS TX
75230-2505
US

IV. Provider business mailing address

PO BOX 201606
DALLAS TX
75320-1606
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-2667
  • Fax:
Mailing address:
  • Phone: 972-758-3598
  • Fax: 972-599-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04313
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: