MEDICARE: MRS. JAMIE PATCH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA08565	TX

General Provider Information

NPI Number	:	1033529730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAMIE PATCH PA-C

Provider Business Mailing Address
First Line	:	928 LIPSCOMB ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3158
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	928 LIPSCOMB ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3158
Country	:	US
Telephone Number	:	817-348-8600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2014
Last Update Date	:	05/02/2014

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