Healthcare Provider Details

I. General information

NPI: 1427116938
Provider Name (Legal Business Name): CISCO MEDICAL CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 HIGHWAY 206
CISCO TX
76437-6447
US

IV. Provider business mailing address

1619 HIGHWAY 206
CISCO TX
76437-6447
US

V. Phone/Fax

Practice location:
  • Phone: 254-442-1441
  • Fax: 254-442-1466
Mailing address:
  • Phone: 254-442-1441
  • Fax: 254-442-1466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00390
License Number StateTX

VIII. Authorized Official

Name: CHARLES NEVIN STEPHENSON
Title or Position: P. A.
Credential: P.A.
Phone: 254-442-1441