Healthcare Provider Details

I. General information

NPI: 1467627349
Provider Name (Legal Business Name): DONNA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SOUTH BROADWAY
ELSA TX
78537
US

IV. Provider business mailing address

PO BOX 337
ELSA TX
78543-0337
US

V. Phone/Fax

Practice location:
  • Phone: 956-262-1304
  • Fax: 956-262-3929
Mailing address:
  • Phone: 956-464-2402
  • Fax: 956-464-5806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03772
License Number StateTX

VIII. Authorized Official

Name: MRS. BELEN CLOSNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 956-262-1304