Provider Demographics
NPI:1104019322
Name:DOBBS, LAUREN GRACE (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:GRACE
Last Name:DOBBS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:GRACE
Other - Last Name:FALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-0349
Mailing Address - Fax:817-735-2653
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-0349
Practice Address - Fax:817-735-2653
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05382363A00000X
OK2283363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191359201Medicaid
TX8Y8724OtherBCBS
TX8K0521Medicare PIN
TX8L25932Medicare PIN