Basic Information
Provider Information
NPI: 1003007311
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLACK
FirstName: MICHAEL
MiddleName: ANTHONY
NamePrefix:  
NameSuffix: SR.
Credential: P.A.-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3600 DARNALL LOOP
Address2: CARL R. DARNALL ARMY MEDICAL CENTER
City: FT HOOD
State: TX
PostalCode: 76544
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3600 DARNALL LOOP
Address2: CARL R. DARNALL ARMY MEDICAL CENTER
City: FT HOOD
State: TX
PostalCode: 76544
CountryCode: US
TelephoneNumber: 2542867927
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/05/2007
LastUpdateDate: 08/05/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XPA10004010WAY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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