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General NPI Number Information
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NPI Number | 1508102559
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Entity Type | Organization
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Legal Business Name | GATOR PA 1ST ASSIST, LLC
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Dates
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Enumeration Date | 12/19/2012
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Last Update Date | 12/19/2012
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Provider Practice Location Address
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Address Line | 10900 STONELAKE BLVD STE A-320
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City | AUSTIN
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State | TX
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Zip | 78759-5833
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Country | US
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Telephone | 866-698-0052
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Fax |
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Provider Business Mailing Address
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Address Line | 10900 STONELAKE BLVD STE A-320
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City | AUSTIN
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State | TX
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Zip | 78759-5833
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Country | US
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Telephone | 866-698-0052
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. PAMELA ANN AHMED
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Credential | PA-C
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Telephone | 972-814-6341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA01673
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License Number State | TX
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