Healthcare Provider Details

I. General information

NPI: 1114404548
Provider Name (Legal Business Name): AMAIRANY MADAI ESCAMILLA MEZA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2018
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E PIONEER PKWY STE 300
GRAND PRAIRIE TX
75051-4984
US

IV. Provider business mailing address

7817 FAIRWEST CT
NORTH RICHLAND HILLS TX
76182-7330
US

V. Phone/Fax

Practice location:
  • Phone: 469-733-1890
  • Fax:
Mailing address:
  • Phone: 817-770-1288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12075
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: