Provider Demographics
NPI:1114534252
Name:LANSDELL FAMILY CLINIC PLLC
Entity Type:Organization
Organization Name:LANSDELL FAMILY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LANSDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-584-1053
Mailing Address - Street 1:500 E COLLIN RAYE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-8068
Mailing Address - Country:US
Mailing Address - Phone:870-584-1053
Mailing Address - Fax:
Practice Address - Street 1:4102 GIBSON LN
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1120
Practice Address - Country:US
Practice Address - Phone:903-255-7923
Practice Address - Fax:866-282-5926
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LANSDELL FAMILY CLINIC PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty