Healthcare Provider Details

I. General information

NPI: 1780621151
Provider Name (Legal Business Name): ALLISON ANN MIRIKE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 N BONNIE BRAE ST SUITE 304
DENTON TX
76201-3708
US

IV. Provider business mailing address

PO BOX 1962
DENTON TX
76202-1962
US

V. Phone/Fax

Practice location:
  • Phone: 940-503-3601
  • Fax: 940-503-3602
Mailing address:
  • Phone: 940-503-3601
  • Fax: 940-503-3602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02831
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: