=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952509317
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE MICHELLE MAYO PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2007
-----------------------------------------------------
Last Update Date | 05/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 MATLOCK RD
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-9164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-453-5437
-----------------------------------------------------
Fax | 817-453-2714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 733784
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75373-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-885-1855
-----------------------------------------------------
Fax | 682-885-1396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA05127
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA05127
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------