1093799025 NPI number — JAMES Y LI MD PA

Table of content: TREVOR JASEN (NPI 1902600893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093799025 NPI number — JAMES Y LI MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAMES Y LI MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1093799025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
540 W 5TH ST
Provider Second Line Business Mailing Address:
SUITE #360
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761-5034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-332-9263
Provider Business Mailing Address Fax Number:
432-332-9264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 W 5TH ST
Provider Second Line Business Practice Location Address:
SUITE #360
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-5034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-332-9263
Provider Business Practice Location Address Fax Number:
432-332-9264
Provider Enumeration Date:
12/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LI
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
432-332-9263

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  L2417 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: L2417 , 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: 176084501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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