Provider Demographics
NPI:1518389980
Name:DE LA FUENTE, KARRAH BLACK (PA)
Entity type:Individual
Prefix:
First Name:KARRAH
Middle Name:BLACK
Last Name:DE LA FUENTE
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 1:6161 N STATE HIGHWAY 161 STE 200
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2220
Mailing Address - Country:US
Mailing Address - Phone:972-258-7499
Mailing Address - Fax:972-870-7303
Practice Address - Street 1:4901 S COLLINS ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-1106
Practice Address - Country:US
Practice Address - Phone:817-960-9134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-20
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08927363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01313385OtherRAILROAD MEDICARE
TXP01313385OtherRAILROAD MEDICARE