Healthcare Provider Details

I. General information

NPI: 1619902848
Provider Name (Legal Business Name): FMC MEDICAL FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 23RD STREET
CANYON TX
79015-4600
US

IV. Provider business mailing address

911 23RD STREET
CANYON TX
79015-4600
US

V. Phone/Fax

Practice location:
  • Phone: 806-655-2104
  • Fax: 806-655-0522
Mailing address:
  • Phone: 806-655-2104
  • Fax: 806-655-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEFANIE FEEMSTER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 806-358-9400