=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134316813
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOROTHEA RENA HAMILTON CSA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2007
-----------------------------------------------------
Last Update Date | 01/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 924 WHITEWATER TRL
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-5443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-345-5074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 924 WHITEWATER TRL
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-5443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-345-5074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 3354
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------