Healthcare Provider Details

I. General information

NPI: 1083928014
Provider Name (Legal Business Name): VENESSA MARIE MAZUR MSPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 8TH AVE STE 650
FORT WORTH TX
76104-4160
US

IV. Provider business mailing address

1250 8TH AVE STE 650
FORT WORTH TX
76104-4160
US

V. Phone/Fax

Practice location:
  • Phone: 817-912-9180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06838
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0003966
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: