MEDICARE: MR. ROBERT CARL HENRY PA-C, MPAS

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	PA03006	TX

General Provider Information

NPI Number	:	1629298583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT CARL HENRY PA-C, MPAS

Provider Business Mailing Address
First Line	:	876 FOX HUNT TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-2354
Country	:	US
Telephone Number	:	682-286-0293
Fax Number	:

Provider Business Practice Location Address
First Line	:	4351 BOOTH CALLOWAY RD
Second Line	:	SUITE 101
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-7378
Country	:	US
Telephone Number	:	817-284-1165
Fax Number	:	817-284-3268

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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