Provider Demographics
NPI:1093188443
Name:TRICIA PUNSALAN MD PA
Entity Type:Organization
Organization Name:TRICIA PUNSALAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PUNSALAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-788-8084
Mailing Address - Street 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2889
Mailing Address - Country:US
Mailing Address - Phone:936-788-8084
Mailing Address - Fax:936-788-8054
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2889
Practice Address - Country:US
Practice Address - Phone:936-788-8084
Practice Address - Fax:936-788-8054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-06
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX461733OtherMEDICARE
TX355446101Medicaid