Healthcare Provider Details

I. General information

NPI: 1003098807
Provider Name (Legal Business Name): DAVID ROBERT DEWALCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 OLYMPIC PLAZA CIR STE 600
TYLER TX
75701-1954
US

IV. Provider business mailing address

700 OLYMPIC PLAZA CIR STE 600
TYLER TX
75701-1954
US

V. Phone/Fax

Practice location:
  • Phone: 903-596-3488
  • Fax:
Mailing address:
  • Phone: 903-596-3488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04127
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: