Provider Demographics
NPI:1023285087
Name:TRI-COUNTY PEDIATRICS PC
Entity type:Organization
Organization Name:TRI-COUNTY PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MNM, CPNP, FNP, BC
Authorized Official - Phone:903-388-5700
Mailing Address - Street 1:703 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-3349
Mailing Address - Country:US
Mailing Address - Phone:903-388-5700
Mailing Address - Fax:
Practice Address - Street 1:703 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEXIA
Practice Address - State:TX
Practice Address - Zip Code:76667-3349
Practice Address - Country:US
Practice Address - Phone:903-388-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX664213363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty