MEDICARE: PAULINA PURNAMA 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	363AS0400X	Surgical Physician Assistant	PA11021	TX

General Provider Information

NPI Number	:	1275724981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULINA PURNAMA PA-C

Provider Business Mailing Address
First Line	:	800 12TH AVE STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2519
Country	:	US
Telephone Number	:	214-631-9881
Fax Number	:	469-482-2526

Provider Business Practice Location Address
First Line	:	800 12TH AVE STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2519
Country	:	US
Telephone Number	:	214-631-9881
Fax Number	:	469-482-2526

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

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	05/03/2025

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Directions to “ PAULINA PURNAMA PA-C” Practice Location

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