Healthcare Provider Details

I. General information

NPI: 1073625497
Provider Name (Legal Business Name): ELIZABETH GAGE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIZ GAGE PA

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 HICKORY CREEK BLVD
HICKORY CREEK TX
75065-7552
US

IV. Provider business mailing address

2124 MILLWOOD DR
CORINTH TX
76210-2218
US

V. Phone/Fax

Practice location:
  • Phone: 713-335-1745
  • Fax:
Mailing address:
  • Phone: 469-441-6613
  • Fax: 940-498-0112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA01853
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: