Basic Information
| Provider Information | |||||||||
| NPI: | 1336454131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | BETTY | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATHISON | ||||||||
| OtherFirstName: | BETTY | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4916 OVERTON PLZ | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175291923 | ||||||||
| FaxNumber: | 8178770350 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175291932 | ||||||||
| FaxNumber: | 8178770350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2010 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1092887 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.