Provider Demographics
NPI:1891154365
Name:WISE COUNTY MEDICAL & SURGICAL ASSOCIATION
Entity Type:Organization
Organization Name:WISE COUNTY MEDICAL & SURGICAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:817-773-8938
Mailing Address - Street 1:1001 W EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3745
Mailing Address - Country:US
Mailing Address - Phone:940-627-8982
Mailing Address - Fax:
Practice Address - Street 1:1001 W EAGLE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3745
Practice Address - Country:US
Practice Address - Phone:940-627-7443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP130210OtherNP LICENSE