1003023979 NPI number — KATRINA L WILLIE-MUSOMA MD

Table of content: KATRINA L WILLIE-MUSOMA MD (NPI 1003023979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003023979 NPI number — KATRINA L WILLIE-MUSOMA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIE-MUSOMA
Provider First Name:
KATRINA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003023979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 E BROAD ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-6410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-557-5437
Provider Business Mailing Address Fax Number:
817-539-0476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 E BROAD ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-6410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-557-5437
Provider Business Practice Location Address Fax Number:
817-539-0476
Provider Enumeration Date:
05/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  M9742 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0008X , with the licence number: M9742 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00R86C . This is a "MEDICARE GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 084933301 . This is a "TMHP/MEDICAID GROUP TPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 195476005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".