Provider Demographics
NPI:1770507493
Name:POMALES, RAFAEL JR (PA)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:POMALES
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 W. LAS COLINAS BLVD
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039
Mailing Address - Country:US
Mailing Address - Phone:972-957-3000
Mailing Address - Fax:972-236-0096
Practice Address - Street 1:1120 E PARKER RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074
Practice Address - Country:US
Practice Address - Phone:469-298-1216
Practice Address - Fax:469-298-1219
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B7353Medicare ID - Type Unspecified
TX181857703Medicaid
TX8C6635Medicare ID - Type Unspecified
TN181857701Medicaid
TXQ03947Medicare UPIN
TX8C6423Medicare ID - Type Unspecified
TN181857702Medicaid