Healthcare Provider Details

I. General information

NPI: 1386064673
Provider Name (Legal Business Name): AMY MAXWELL MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 GATEWAY BLVD W SUITE 140
EL PASO TX
79925-7934
US

IV. Provider business mailing address

PO BOX 220122
EL PASO TX
79913-2122
US

V. Phone/Fax

Practice location:
  • Phone: 915-544-7300
  • Fax:
Mailing address:
  • Phone: 915-740-5122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM3317
License Number StateTX

VIII. Authorized Official

Name: JESUS FERNANDO ESCARZAGA
Title or Position: MANAGER
Credential:
Phone: 915-740-5122