1295937449 NPI number — PUCKETT FAMILY CLINIC, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295937449 NPI number — PUCKETT FAMILY CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUCKETT FAMILY CLINIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1295937449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 166
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONEY GROVE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75446-0166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-378-3444
Provider Business Mailing Address Fax Number:
903-378-3445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONEY GROVE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75446-1268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-378-3444
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PUCKETT
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
LAVAL
Authorized Official Title or Position:
PHYSICIAN ASSISTANT - CERTIFIED
Authorized Official Telephone Number:
903-378-3444

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA02778 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: PA02778 , 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: PA02778 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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