Provider Demographics
NPI:1417060971
Name:KHONCARLY, DANIA (PA)
Entity Type:Individual
Prefix:
First Name:DANIA
Middle Name:
Last Name:KHONCARLY
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 913
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-0913
Mailing Address - Country:US
Mailing Address - Phone:972-991-9950
Mailing Address - Fax:972-991-4026
Practice Address - Street 1:3200 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2911
Practice Address - Country:US
Practice Address - Phone:817-419-1876
Practice Address - Fax:817-419-4284
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J8391Medicare PIN