Healthcare Provider Details

I. General information

NPI: 1023018645
Provider Name (Legal Business Name): PAMELA JEAN PLAKE P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 NINTH AVE SUITE 300
FORT WORTH TX
76104
US

IV. Provider business mailing address

909 NINTH AVE SUITE 300
FORT WORTH TX
76104-3917
US

V. Phone/Fax

Practice location:
  • Phone: 817-336-7191
  • Fax: 817-332-3172
Mailing address:
  • Phone: 817-336-7191
  • Fax: 817-332-3172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00619
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: