Provider Demographics
NPI:1013431642
Name:MAINOUS, PAMELA J
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:MAINOUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 N BURLESON BLVD # 107-233
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7011
Mailing Address - Country:US
Mailing Address - Phone:817-269-1472
Mailing Address - Fax:817-531-2939
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4101
Practice Address - Country:US
Practice Address - Phone:817-346-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO94494246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant