Provider Demographics
NPI:1275724981
Name:PURNAMA, PAULINA (PA-C)
Entity Type:Individual
Prefix:
First Name:PAULINA
Middle Name:
Last Name:PURNAMA
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 1:2600 E SOUTHLAKE BLVD STE 120-177
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6634
Mailing Address - Country:US
Mailing Address - Phone:469-708-3989
Mailing Address - Fax:
Practice Address - Street 1:2600 E SOUTHLAKE BLVD STE 120-177
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6634
Practice Address - Country:US
Practice Address - Phone:469-708-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11021363AS0400X
NY23011976363AS0400X
NDPAC0463363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN716898Medicare PIN