MEDICARE: KELLY DOTSON

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	363A00000X	Physician Assistant	PA20072	TX

General Provider Information

NPI Number	:	1164230504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DOTSON

Provider Business Mailing Address
First Line	:	3900 JUNIUS ST STE 705
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75246-1627
Country	:	US
Telephone Number	:	972-817-7450
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 JUNIUS ST STE 705
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75246-1627
Country	:	US
Telephone Number	:	972-817-7450
Fax Number	:

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

Provider Enumeration Date	:	12/18/2024
Last Update Date	:	06/09/2026

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