Healthcare Provider Details

I. General information

NPI: 1366836355
Provider Name (Legal Business Name): TEXAS PRIMARY CARE GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 PRECINCT LINE RD SUITE 200
HURST TX
76054-3169
US

IV. Provider business mailing address

4730 N HABANA AVE SUITE 204
TAMPA FL
33614-7163
US

V. Phone/Fax

Practice location:
  • Phone: 817-369-3990
  • Fax: 817-514-1901
Mailing address:
  • Phone: 813-549-2134
  • Fax: 813-870-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TRACIE LAWSON
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: APRN
Phone: 813-549-2134