Provider Demographics
NPI:1114291192
Name:MIXON, MAILE
Entity Type:Individual
Prefix:
First Name:MAILE
Middle Name:
Last Name:MIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 W SPRING CREEK PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-4236
Mailing Address - Country:US
Mailing Address - Phone:972-599-9600
Mailing Address - Fax:972-599-9696
Practice Address - Street 1:8080 INDEPENDENCE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025-4000
Practice Address - Country:US
Practice Address - Phone:972-596-9511
Practice Address - Fax:972-867-8163
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant