Provider Demographics
NPI:1316250111
Name:EAST TEXAS PHYSICIAN ALLICANCE
Entity type:Organization
Organization Name:EAST TEXAS PHYSICIAN ALLICANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-731-4700
Mailing Address - Street 1:PO BOX 4550
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-4550
Mailing Address - Country:US
Mailing Address - Phone:903-731-4555
Mailing Address - Fax:903-731-4699
Practice Address - Street 1:3201 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6901
Practice Address - Country:US
Practice Address - Phone:903-731-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty