Provider Demographics
NPI:1104196534
Name:BLACK, JOELLE IONE (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:IONE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:JOELLE
Other - Middle Name:IONE
Other - Last Name:CHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-0001
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:254-724-7603
Is Sole Proprietor?:No
Enumeration Date:2012-01-02
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN