MEDICARE: MISSION METROPLEX, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1063049625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSION METROPLEX, INC.

Provider Business Mailing Address
First Line	:	210 W SOUTH ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-7134
Country	:	US
Telephone Number	:	817-277-6620
Fax Number	:	817-277-3388

Provider Business Practice Location Address
First Line	:	212 W SOUTH ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-7134
Country	:	US
Telephone Number	:	817-277-9597
Fax Number	:	817-766-7016

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	SYLVIA BURGIN
Credential	:
Telephone Number	:	817-929-5080

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	03/24/2020

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