Organization
PEDIATRIC SURGICAL ASSOCIATES OF FT. WORTH, P. A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEBRA LOCKETT (ADMINISTRATOR)
(817) 336-7881
Entity
Organization
Contact information
Practice address
901 7TH AVE, SUITE 210, FORT WORTH, TX 76104-2722
(817) 336-7881
(817) 336-6821
Mailing address
901 7TH AVE, SUITE 210, FORT WORTH, TX 76104-2722
(817) 336-7881
(817) 336-6821
Taxonomy
Speciality
Code
Description
License number
State
2086S0120X
Pediatric Surgery Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
112632802
—
TX
05
—
112632804
—
TX
01
—
4641193
AETNA
TX
Enumeration date
11/07/2005
Last updated
06/17/2010
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