Healthcare Provider Details

I. General information

NPI: 1588945448
Provider Name (Legal Business Name): TONY PHANSANA CST/FA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 02/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9156 BROOK HILL LN
FORT WORTH TX
76244-4930
US

IV. Provider business mailing address

9156 BROOK HILL LN
FORT WORTH TX
76244-4930
US

V. Phone/Fax

Practice location:
  • Phone: 817-726-7644
  • Fax:
Mailing address:
  • Phone: 817-726-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number129282
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: