Healthcare Provider Details

I. General information

NPI: 1346242567
Provider Name (Legal Business Name): PRIVIA MEDICAL GROUP WEST TEXAS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 ANTILLEY RD # 200
ABILENE TX
79606-5265
US

IV. Provider business mailing address

PO BOX 5409
ABILENE TX
79608-5409
US

V. Phone/Fax

Practice location:
  • Phone: 325-793-5375
  • Fax: 325-793-5384
Mailing address:
  • Phone: 325-437-8655
  • Fax: 325-437-8647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ANDREW KOUBA
Title or Position: CEO/AUTHORIZED OFFICIAL
Credential:
Phone: 325-437-8645