=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538486246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDASSISTLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2010
-----------------------------------------------------
Last Update Date | 04/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1626 W HIGHWAY 287 BUSINESS 107
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-937-7240
-----------------------------------------------------
Fax | 972-937-4255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1626 W HIGHWAY 287 BUSINESS 107
-----------------------------------------------------
City | WAXAHACHIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75165-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-937-7240
-----------------------------------------------------
Fax | 972-937-4255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TOM ELLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-937-7240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------