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General NPI Number Information
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NPI Number | 1629325501
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Entity Type | Individual
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Provider Name | MISHA HOUSTON PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/09/2012
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Last Update Date | 12/16/2019
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Provider Practice Location Address
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Address Line | 1611 E 7TH ST
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City | CHARLOTTE
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State | NC
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Zip | 28204-2411
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Country | US
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Telephone | 704-970-4106
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Fax |
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Provider Business Mailing Address
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Address Line | 414 KATONAH AVE
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City | CHARLOTTE
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State | NC
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Zip | 28208-4320
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Country | US
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Telephone |
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Fax |
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA12172
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 001009182
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License Number State | NC
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