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General NPI Number Information
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NPI Number | 1508556028
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Entity Type | Individual
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Provider Name | JOHN DAVID DEETJEN PA-C
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Gender | Male
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Dates
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Enumeration Date | 05/09/2023
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Last Update Date | 05/09/2023
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Provider Practice Location Address
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Address Line | 1201 FAIRMOUNT AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-4215
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Country | US
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Telephone | 817-335-5288
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Fax | 817-338-0927
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Provider Business Mailing Address
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Address Line | 6100 HARRIS PKWY STE 285
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City | FORT WORTH
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State | TX
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Zip | 76132-4127
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Country | US
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Telephone | 817-263-5864
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Fax | 817-394-6294
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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