Provider Demographics
NPI:1043209869
Name:VIDAL, PRISCILA (ARNP)
Entity Type:Individual
Prefix:
First Name:PRISCILA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORTH WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8450
Mailing Address - Fax:
Practice Address - Street 1:74 MCMAKIN RD STE 205
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:TX
Practice Address - Zip Code:76226-8438
Practice Address - Country:US
Practice Address - Phone:940-455-7200
Practice Address - Fax:305-682-1602
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1008694363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307221500Medicaid