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General NPI Number Information
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NPI Number | 1730192428
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Entity Type | Individual
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Provider Name | MISTIE B LUCHTEL-ROSS PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 5200 HARRY HINES BLVD
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City | DALLAS
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State | TX
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Zip | 75390-3200
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Country | US
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Telephone | 469-419-0872
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Fax | 214-419-9220
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Provider Business Mailing Address
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Address Line | 6451 BRENTWOOD STAIR RD STE 200
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City | FT WORTH
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State | TX
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Zip | 76112-3200
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Country | US
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Telephone | 817-507-0796
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Fax | 817-507-0797
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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 | PA919
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA04492
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License Number State | TX
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