Healthcare Provider Details

I. General information

NPI: 1487791562
Provider Name (Legal Business Name): JACKIE LYNNE FLUHARTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2487 RICKER ROAD WBAMC
FT BLISS TX
79916
US

IV. Provider business mailing address

3513 RIVERSTONE DR
EL PASO TX
79936-0699
US

V. Phone/Fax

Practice location:
  • Phone: 915-569-4387
  • Fax:
Mailing address:
  • Phone: 915-269-5571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04480
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: