Provider Demographics
NPI:1578684197
Name:PERMIAN FAMILY CLINIC
Entity Type:Organization
Organization Name:PERMIAN FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:RONELL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:CSFNP
Authorized Official - Phone:432-362-8400
Mailing Address - Street 1:509 DELMAR ST
Mailing Address - Street 2:APT 402
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-5572
Mailing Address - Country:US
Mailing Address - Phone:432-362-8400
Mailing Address - Fax:432-362-8407
Practice Address - Street 1:4039 E 42ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5935
Practice Address - Country:US
Practice Address - Phone:432-362-8400
Practice Address - Fax:432-362-8407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX532880363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N5086OtherBCBS
TX8N5086OtherBCBS
TXS68706Medicare UPIN