Basic Information
| Provider Information | |||||||||
| NPI: | 1558496067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | TONI | ||||||||
| MiddleName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1831 | ||||||||
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| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755041831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037921292 | ||||||||
| FaxNumber: | 9037922051 | ||||||||
| Practice Location | |||||||||
| Address1: | 5508 SUMMERHILL RD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755031822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037921292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247100000X | 279307 | TX | N | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | 363AM0700X | 06TX1185 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.