1699113274 NPI number — JIA WEN JESSICA CHANG M.D.

Table of content: GREGORY R BROTSKE APRN (NPI 1366292229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699113274 NPI number — JIA WEN JESSICA CHANG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHANG
Provider First Name:
JIA WEN
Provider Middle Name:
JESSICA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHANG
Provider Other First Name:
CHIA WEN
Provider Other Middle Name:
JESSICA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1699113274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 844658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-4658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-724-2111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROUND ROCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78665-1032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-509-0100
Provider Business Practice Location Address Fax Number:
512-218-6330
Provider Enumeration Date:
06/05/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  A131810 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: Q7540 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)