Basic Information
| Provider Information | |||||||||
| NPI: | 1396193066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICAREPRO OF TEXAS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9178 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728119178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554986767 | ||||||||
| FaxNumber: | 4799681673 | ||||||||
| Practice Location | |||||||||
| Address1: | 4140 MCKNIGHT RD STE D | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755030921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554986767 | ||||||||
| FaxNumber: | 4799681673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2016 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | THOMASON | ||||||||
| AuthorizedOfficialFirstName: | AYASHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5018311168 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.