Healthcare Provider Details

I. General information

NPI: 1770019283
Provider Name (Legal Business Name): JOSEPH MARTIN CUELLAR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

779 GRAPEVINE HWY
HURST TX
76054-2805
US

IV. Provider business mailing address

645 E STATE HIGHWAY 121 STE 600
COPPELL TX
75019-7942
US

V. Phone/Fax

Practice location:
  • Phone: 817-428-7300
  • Fax: 817-428-1085
Mailing address:
  • Phone: 972-906-8107
  • Fax: 972-956-8887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11384
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: