Healthcare Provider Details

I. General information

NPI: 1316250111
Provider Name (Legal Business Name): EAST TEXAS PHYSICIAN ALLICANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S LOOP 256
PALESTINE TX
75801-6901
US

IV. Provider business mailing address

PO BOX 4550
PALESTINE TX
75802-4550
US

V. Phone/Fax

Practice location:
  • Phone: 903-731-4555
  • Fax:
Mailing address:
  • Phone: 903-731-4555
  • Fax: 903-731-4699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLEY GIBSON
Title or Position: ADMINSTRATOR
Credential:
Phone: 903-731-4700