Healthcare Provider Details

I. General information

NPI: 1487870069
Provider Name (Legal Business Name): DIANA L GARRISON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 GASTON AVE STE 302
DALLAS TX
75246-2532
US

IV. Provider business mailing address

3801 GASTON AVE STE 302
DALLAS TX
75246-2532
US

V. Phone/Fax

Practice location:
  • Phone: 214-828-0016
  • Fax: 214-828-4883
Mailing address:
  • Phone: 214-828-0016
  • Fax: 214-828-4883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA02587
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: