Provider Demographics
NPI:1831501642
Name:PRO PHYSICIANS CLINIC PA
Entity Type:Organization
Organization Name:PRO PHYSICIANS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:JON TRYGGESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-573-4611
Mailing Address - Street 1:PO BOX 678234
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8234
Mailing Address - Country:US
Mailing Address - Phone:316-869-2280
Mailing Address - Fax:512-583-2001
Practice Address - Street 1:2077 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3411
Practice Address - Country:US
Practice Address - Phone:316-869-2280
Practice Address - Fax:512-583-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04264472085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty