| Lake Dallas Family Medicine Pllc | |
|
503 Main St Ste C Lake Dallas TX 75065-2878 | |
| (940) 535-5296 | |
| (940) 535-5297 |
| Full Name | Lake Dallas Family Medicine Pllc |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 503 Main St Ste C, Lake Dallas, Texas |
| Authorized Official Name and Position | Carmen Phillips White (OWNER) |
| Authorized Official Contact | 2149086012 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake Dallas Family Medicine Pllc 503 Main St Ste C Lake Dallas TX 75065-2878 Ph: (940) 535-5296 | Lake Dallas Family Medicine Pllc 503 Main St Ste C Lake Dallas TX 75065-2878 Ph: (940) 535-5296 |
| NPI Number | 1871158907 |
|---|---|
| Provider Enumeration Date | 05/03/2019 |
| Last Update Date | 06/19/2019 |
| Medicare PECOS PAC ID | 3274863394 |
|---|---|
| Medicare Enrollment ID | O20191002001957 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1871158907 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Secondary |
| 363LF0000X | Nurse Practitioner - Family | (* (Not Available)) | Primary |
| Provider Name | Gayla M Reach |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1942395900 PECOS PAC ID: 5698765287 Enrollment ID: I20040515000099 |
| Provider Name | Carmen Phillips White |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1689831562 PECOS PAC ID: 2567625122 Enrollment ID: I20120517000309 |
| Provider Name | Madisen Tayler Stacks |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1063004158 PECOS PAC ID: 1456757384 Enrollment ID: I20210901001351 |