Provider Demographics
NPI:1962966614
Name:MCNAIR, PERONICA
Entity type:Individual
Prefix:
First Name:PERONICA
Middle Name:
Last Name:MCNAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8063 VISTA HILL LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75249-2031
Mailing Address - Country:US
Mailing Address - Phone:972-816-8067
Mailing Address - Fax:
Practice Address - Street 1:2100 N HWY 360 STE 2200A
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1043
Practice Address - Country:US
Practice Address - Phone:972-816-8067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11700771744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management