Provider Demographics
NPI:1194984757
Name:UT SOUTHWESTERN MEDICAL CENTER
Entity type:Organization
Organization Name:UT SOUTHWESTERN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:WISAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NACHAWATI
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:972-451-0617
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:972-451-0617
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:972-451-0617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-08
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04785282N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care Hospital