Healthcare Provider Details

I. General information

NPI: 1063516789
Provider Name (Legal Business Name): DALLAS VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S LANCASTER RD
DALLAS TX
75216-7167
US

IV. Provider business mailing address

3418 JASPER DR
GRAND PRAIRIE TX
75052-7871
US

V. Phone/Fax

Practice location:
  • Phone: 214-857-1713
  • Fax:
Mailing address:
  • Phone: 972-352-5533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01808
License Number StateTX

VIII. Authorized Official

Name: MS. MARGIE A PRIOLEAU
Title or Position: PHYSICIAN ASSISTANCE
Credential:
Phone: 214-857-1734