Provider Demographics
NPI:1891237962
Name:MIRABAL, WILLIAM ELIAS (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ELIAS
Last Name:MIRABAL
Suffix:
Gender:M
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 1:2608 MCDONALD RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5934
Mailing Address - Country:US
Mailing Address - Phone:903-595-5514
Mailing Address - Fax:
Practice Address - Street 1:2608 MCDONALD RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5934
Practice Address - Country:US
Practice Address - Phone:903-595-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10979363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical