Healthcare Provider Details

I. General information

NPI: 1518538115
Provider Name (Legal Business Name): SYDNEY MIKA PERALTA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 07/05/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 41ST ST SE
PARIS TX
75462-8207
US

IV. Provider business mailing address

305 COUNTY ROAD 45800
BLOSSOM TX
75416-2991
US

V. Phone/Fax

Practice location:
  • Phone: 903-739-7700
  • Fax:
Mailing address:
  • Phone: 903-517-6925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number1046657
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1046657
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: