Healthcare Provider Details

I. General information

NPI: 1376565341
Provider Name (Legal Business Name): MEDISTAT GROUP ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 BOLTON BOONE DR SUITE B
DESOTO TX
75115-2074
US

IV. Provider business mailing address

2617 BOLTON BOONE DR SUITE B
DESOTO TX
75115-2074
US

V. Phone/Fax

Practice location:
  • Phone: 972-709-1781
  • Fax: 972-709-1782
Mailing address:
  • Phone: 972-709-1781
  • Fax: 972-709-1782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberG6955
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225B00000X
TaxonomyPulmonary Function Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2278P1005X
TaxonomyPulmonary Rehabilitation Certified Respiratory Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TERI LOUISE SHIPMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 972-709-1781