Provider Demographics
NPI:1952496929
Name:MYRNA C DE ASIS MD PA
Entity Type:Organization
Organization Name:MYRNA C DE ASIS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT, OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:DESNACIDO
Authorized Official - Last Name:DE ASIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-763-8077
Mailing Address - Street 1:PO BOX 4710
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308
Mailing Address - Country:US
Mailing Address - Phone:940-763-8077
Mailing Address - Fax:
Practice Address - Street 1:1819 TENTH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5012
Practice Address - Country:US
Practice Address - Phone:940-763-8077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164418901Medicaid
TX45D0942509OtherCLIA
TX45D0942509OtherCLIA
TX00755VMedicare PIN