Provider Demographics
NPI:1790889004
Name:MEWBOURNE, TRICIA NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:NICOLE
Last Name:MEWBOURNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 INDEPENDENCE PKWY
Mailing Address - Street 2:STE 230
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-4013
Mailing Address - Country:US
Mailing Address - Phone:972-985-2797
Mailing Address - Fax:972-985-4797
Practice Address - Street 1:4708 ALLIANCE BLVD
Practice Address - Street 2:SUITE 810
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5340
Practice Address - Country:US
Practice Address - Phone:972-985-2797
Practice Address - Fax:972-985-4797
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07016363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51004134OtherBLUE CROSS BLUE SHIELD
AL009939411Medicaid
AL009939411Medicaid
ALQ72239Medicare UPIN