Provider Demographics
NPI:1730192428
Name:LUCHTEL-ROSS, MISTIE B (PA-C)
Entity type:Individual
Prefix:
First Name:MISTIE
Middle Name:B
Last Name:LUCHTEL-ROSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6451 BRENTWOOD STAIR RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-3200
Mailing Address - Country:US
Mailing Address - Phone:817-507-0796
Mailing Address - Fax:817-507-0797
Practice Address - Street 1:5200 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-3200
Practice Address - Country:US
Practice Address - Phone:469-419-0872
Practice Address - Fax:214-419-9220
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA919363A00000X
TXPA04492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVQ51513Medicare UPIN
NVBE6067Medicare PIN
NV101304Medicare ID - Type Unspecified