Provider Demographics
NPI:1386626836
Name:SCHORCK, JOHANNA B (PA)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:B
Last Name:SCHORCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:102 E YOUNG ST
Practice Address - Street 2:
Practice Address - City:LLANO
Practice Address - State:TX
Practice Address - Zip Code:78643-1349
Practice Address - Country:US
Practice Address - Phone:325-247-4131
Practice Address - Fax:325-248-2099
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10013424OtherAMERIGROUP
R59670Medicare UPIN
TX87N962Medicare PIN
TX10013424OtherAMERIGROUP