Provider Demographics
NPI:1184064792
Name:HUDDLESTON, DANISHA M
Entity type:Individual
Prefix:
First Name:DANISHA
Middle Name:M
Last Name:HUDDLESTON
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 1:800 8TH AVE
Mailing Address - Street 2:SUITE 616
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2601
Mailing Address - Country:US
Mailing Address - Phone:682-224-3748
Mailing Address - Fax:682-841-0039
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:SUITE 616
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2601
Practice Address - Country:US
Practice Address - Phone:682-224-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135895OtherCERTIFIED SURGICAL FIRST ASSISTANT