MEDICARE: MR. DARRELL WAYNE WORTHEM SR. LSA

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	246ZC0007X	Surgical Assistant	SA00816	TX

General Provider Information

NPI Number	:	1922625920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARRELL WAYNE WORTHEM SR. LSA

Provider Business Mailing Address
First Line	:	3500 DANIEL DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76014-3335
Country	:	US
Telephone Number	:	817-901-0943
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 W SEVENTH ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76102-3510
Country	:	US
Telephone Number	:	682-885-4105
Fax Number	:

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

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	06/25/2020

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