Healthcare Provider Details

I. General information

NPI: 1770965675
Provider Name (Legal Business Name): DENA RAE GEBRIL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DENA RAE HERNANDEZ

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST FL 3
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-6828
  • Fax:
Mailing address:
  • Phone: 214-645-4673
  • Fax: 972-669-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09876
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: