MEDICARE: MISS GAIL TYRIA HOUSTON 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	C100031	MD

General Provider Information

NPI Number	:	1316929888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS GAIL TYRIA HOUSTON PA-C

Provider Business Mailing Address
First Line	:	2412 MOUNTAIN RD
Second Line	:
City	:	JOPPA
State	:	MD
Zip	:	21085-2338
Country	:	US
Telephone Number	:	410-262-4305
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 GRANT AVE
Second Line	:	ROOM 1809
City	:	FORT LEAVENWORTH
State	:	KS
Zip	:	66027-1231
Country	:	US
Telephone Number	:	913-758-3791
Fax Number	:

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

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	07/08/2007

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