Healthcare Provider Details

I. General information

NPI: 1215967823
Provider Name (Legal Business Name): DAVID HUSTON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 ROSELAND BLVD SUITE 200
TYLER TX
75701-4262
US

IV. Provider business mailing address

1814 ROSELAND BLVD SUITE 200
TYLER TX
75701-4262
US

V. Phone/Fax

Practice location:
  • Phone: 903-531-2500
  • Fax: 903-592-4468
Mailing address:
  • Phone: 903-531-2500
  • Fax: 903-592-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04182
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: