Provider Demographics
NPI:1093204158
Name:PRIMARY FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:PRIMARY FAMILY MEDICAL CLINIC
Other - Org Name:PRIMARY FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,
Authorized Official - Phone:601-372-1221
Mailing Address - Street 1:100 MARKETPLACE DR STE D
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-8974
Mailing Address - Country:US
Mailing Address - Phone:601-372-1221
Mailing Address - Fax:769-300-8086
Practice Address - Street 1:100 MARKER PLACE DR. STE D
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272
Practice Address - Country:US
Practice Address - Phone:601-672-4661
Practice Address - Fax:769-300-8068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR772161363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty