Healthcare Provider Details

I. General information

NPI: 1104996735
Provider Name (Legal Business Name): MEDICAL PARKWAY FAMILY PRACTICE,LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 RICHLAND WEST CIR SUITE A
WACO TX
76712-7919
US

IV. Provider business mailing address

318 RICHLAND WEST CIR SUITE A
WACO TX
76712-7919
US

V. Phone/Fax

Practice location:
  • Phone: 254-776-8008
  • Fax: 254-776-6892
Mailing address:
  • Phone: 254-776-8008
  • Fax: 254-776-6892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA JOHNSON KIRK
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 254-776-8008