Provider Demographics
NPI:1760808935
Name:FAMILY MEDICINE ASSOCIATES PA
Entity Type:Organization
Organization Name:FAMILY MEDICINE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:OLIVE
Authorized Official - Last Name:GASSAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-668-0414
Mailing Address - Street 1:251 E SOUTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6269
Mailing Address - Country:US
Mailing Address - Phone:817-925-4309
Mailing Address - Fax:
Practice Address - Street 1:220 N RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4115
Practice Address - Country:US
Practice Address - Phone:817-556-4800
Practice Address - Fax:817-774-5034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-12
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX604322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX604322OtherLICENSE