Provider Demographics
NPI:1558496067
Name:BROWN, TONI DENISE
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:DENISE
Last Name:BROWN
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:PO BOX 1831
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75504-1831
Mailing Address - Country:US
Mailing Address - Phone:903-792-1292
Mailing Address - Fax:903-792-2051
Practice Address - Street 1:5508 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1822
Practice Address - Country:US
Practice Address - Phone:903-792-1292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279307247100000X
TX06TX1185363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist