Provider Demographics
NPI:1902100597
Name:MACHUCA, JULIE ANNETTE (PA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANNETTE
Last Name:MACHUCA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9003 AIRPORT FWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-7770
Mailing Address - Country:US
Mailing Address - Phone:817-514-5200
Mailing Address - Fax:817-514-5210
Practice Address - Street 1:1300 W TERRELL AVE STE 405
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2810
Practice Address - Country:US
Practice Address - Phone:817-303-4521
Practice Address - Fax:817-468-5876
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA07108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB131520Medicare PIN
TX350959YLLVMedicare PIN
TXTXB131519Medicare PIN