Provider Demographics
NPI:1083259022
Name:DAIGLE, KATHLEEN DURHAM (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DURHAM
Last Name:DAIGLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4168 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-5687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7630 N BEACH ST STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3016
Practice Address - Country:US
Practice Address - Phone:817-281-2977
Practice Address - Fax:817-788-2530
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant