Healthcare Provider Details

I. General information

NPI: 1487184792
Provider Name (Legal Business Name): WEST MAGNOLIA PLASTIC SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W MAGNOLIA AVE STE 110
FORT WORTH TX
76104-4488
US

IV. Provider business mailing address

1200 W MAGNOLIA AVE STE 110
FORT WORTH TX
76104-4488
US

V. Phone/Fax

Practice location:
  • Phone: 817-870-4833
  • Fax: 817-870-4893
Mailing address:
  • Phone: 817-870-4833
  • Fax: 817-870-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number7481
License Number StateTX

VIII. Authorized Official

Name: MS. EMILY B MCLAUGHLIN
Title or Position: OWNER
Credential: MD
Phone: 817-870-4833