Provider Demographics
NPI:1720037476
Name:DEPARTMENT OF VETERANS AFFAIRS
Entity Type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TOM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:903-583-6307
Mailing Address - Street 1:1201 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BONHAM
Mailing Address - State:TX
Mailing Address - Zip Code:75418-4059
Mailing Address - Country:US
Mailing Address - Phone:903-583-6307
Mailing Address - Fax:903-583-6339
Practice Address - Street 1:1201 E 9TH ST
Practice Address - Street 2:
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-4059
Practice Address - Country:US
Practice Address - Phone:903-583-6307
Practice Address - Fax:903-583-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04043261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04043OtherTX STATE BOARD OF PA EXAM
1031923OtherNCCPA