Provider Demographics
NPI:1972812493
Name:UNG, BOTHLAND (PA-C, MS)
Entity Type:Individual
Prefix:
First Name:BOTHLAND
Middle Name:
Last Name:UNG
Suffix:
Gender:F
Credentials:PA-C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13802 CENTERFIELD DR STE 185
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-6043
Mailing Address - Country:US
Mailing Address - Phone:281-737-4425
Mailing Address - Fax:
Practice Address - Street 1:13802 CENTERFIELD DR STE 185
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070
Practice Address - Country:US
Practice Address - Phone:281-737-4425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282016902Medicaid
TX1972812493OtherBLUE CROSS BLUE SHIELD
TX282016901Medicaid