Healthcare Provider Details

I. General information

NPI: 1386924801
Provider Name (Legal Business Name): MANJOT KAUR GILL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 PENNSYLVANIA AVE STE 690
FORT WORTH TX
76104-2133
US

IV. Provider business mailing address

462 1ST AVE
NEW YORK NY
10016-9196
US

V. Phone/Fax

Practice location:
  • Phone: 817-761-7740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number015024
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA12111
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: