Provider Demographics
NPI:1134538895
Name:EAST TEXAS PRECISION MEDICINE, PLLC
Entity type:Organization
Organization Name:EAST TEXAS PRECISION MEDICINE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AM
Authorized Official - Prefix:
Authorized Official - First Name:GALYNN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-576-2355
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-0045
Mailing Address - Country:US
Mailing Address - Phone:903-320-3200
Mailing Address - Fax:903-471-8655
Practice Address - Street 1:1600 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-6852
Practice Address - Country:US
Practice Address - Phone:903-320-3200
Practice Address - Fax:903-471-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126149364SG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP126149OtherLICENSE