Basic Information
| Provider Information | |||||||||
| NPI: | 1790729663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HILL | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177597000 | ||||||||
| FaxNumber: | 8178828053 | ||||||||
| Practice Location | |||||||||
| Address1: | 11805 SOUTH FWY STE 201 | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760287220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177597000 | ||||||||
| FaxNumber: | 8177597027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 04/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01940 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1947418-11 | 05 | TX | MEDICAID | 1947418-10 | 05 | TX | MEDICAID | 8550NQ | 01 | BCBS | OTHER |