Provider Demographics
NPI:1518538115
Name:PERALTA, SYDNEY MIKA (FNP-C)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:MIKA
Last Name:PERALTA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 COUNTY ROAD 45800
Mailing Address - Street 2:
Mailing Address - City:BLOSSOM
Mailing Address - State:TX
Mailing Address - Zip Code:75416-2991
Mailing Address - Country:US
Mailing Address - Phone:903-517-6925
Mailing Address - Fax:
Practice Address - Street 1:2675 41ST ST SE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75462-8207
Practice Address - Country:US
Practice Address - Phone:903-739-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1046657207QA0505X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1046657OtherTEXAS BON