Basic Information
| Provider Information | |||||||||
| NPI: | 1447383385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONROE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144567000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1935 MEDICAL DISTRICT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144567000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA04464 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA04464 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 818N32 | 01 | TX | BCBS | OTHER | PA04464 | 01 | TX | STATE LICENSE | OTHER |