Basic Information
| Provider Information | |||||||||
| NPI: | 1518389980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA FUENTE | ||||||||
| FirstName: | KARRAH | ||||||||
| MiddleName: | BLACK | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6161 N STATE HIGHWAY 161 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750382220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722587499 | ||||||||
| FaxNumber: | 9722570897 | ||||||||
| Practice Location | |||||||||
| Address1: | 6161 N HIGHWAY 161 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722587499 | ||||||||
| FaxNumber: | 9722570897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2014 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P01313385 | 01 | TX | RAILROAD MEDICARE | OTHER |