Provider Demographics
NPI:1316929888
Name:HOUSTON, GAIL TYRIA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:GAIL
Middle Name:TYRIA
Last Name:HOUSTON
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 1:2412 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-2338
Mailing Address - Country:US
Mailing Address - Phone:410-262-4305
Mailing Address - Fax:
Practice Address - Street 1:210 GRANT AVE
Practice Address - Street 2:ROOM 1809
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-1231
Practice Address - Country:US
Practice Address - Phone:913-758-3791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC100031363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical