=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417001470
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAROLD D HEALD PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 06/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 STATE HIGHWAY 121 APT 1005
-----------------------------------------------------
City | EULESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76039-2482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-629-6307
-----------------------------------------------------
Fax | 972-255-8922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 COTTONWOOD LN SUITE 100
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75038-6117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-258-7499
-----------------------------------------------------
Fax | 972-255-8922
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA01766
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------