Healthcare Provider Details

I. General information

NPI: 1760831770
Provider Name (Legal Business Name): JMC PROFESSIONAL SURGICAL ASSOCIATE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 SCENIC DR
TYLER TX
75709-5402
US

IV. Provider business mailing address

PO BOX 8943
TYLER TX
75711-8943
US

V. Phone/Fax

Practice location:
  • Phone: 888-322-6432
  • Fax: 888-329-6432
Mailing address:
  • Phone: 888-322-6432
  • Fax: 888-329-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number521694
License Number StateTX

VIII. Authorized Official

Name: MRS. JULIE CONLEY
Title or Position: OWNER
Credential: RNFA
Phone: 888-322-6432