1982624169 NPI number — WAYNE D WAYT PAC

Table of content: WAYNE D WAYT PAC (NPI 1982624169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982624169 NPI number — WAYNE D WAYT PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAYT
Provider First Name:
WAYNE
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982624169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 TELLURIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76001-8518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-688-6152
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 E DAWSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-2036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-606-4262
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2006

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: 363A00000X , with the licence number:  PA04132 , 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)

  • Identifier: 290254618 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA04132 . This is a "PHYSICIAN ASSISTANTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1J7443 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P02601593 . This is a "MCRR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 290254601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1J7442 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 290254603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 290254602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q00010982 . This is a "MCRR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 107297200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com