Basic Information
| Provider Information | |||||||||
| NPI: | 1336312412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSTROM | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 N PIEDRAS | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799306400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155646100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5001 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799304210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155646100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2008 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0700X | 011404 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TB0200X | 011404 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 011404 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | 011404 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TH0004X | 011404 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Health |
ID Information
| ID | Type | State | Issuer | Description | 01605669 | 05 | NY | MEDICAID |