Provider Demographics
NPI:1568760981
Name:MBI, PRYSCA N (MD)
Entity Type:Individual
Prefix:
First Name:PRYSCA
Middle Name:N
Last Name:MBI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 CLEARFORK MAIN ST
Mailing Address - Street 2:STE 230
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3500
Mailing Address - Country:US
Mailing Address - Phone:817-984-1687
Mailing Address - Fax:
Practice Address - Street 1:5450 CLEARFORK MAIN ST
Practice Address - Street 2:STE 230
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-3500
Practice Address - Country:US
Practice Address - Phone:817-984-1687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2341207Q00000X
GA65716207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX349439502Medicaid
TX349439501Medicaid
TX433200YNGSMedicare PIN
TX433200YL7AMedicare PIN