1396292918 NPI number — DEANNE WHEELER H. I. S.

Table of content: DEANNE WHEELER H. I. S. (NPI 1396292918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396292918 NPI number — DEANNE WHEELER H. I. S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHEELER
Provider First Name:
DEANNE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
H. I. S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHEELER
Provider Other First Name:
MARILYN
Provider Other Middle Name:
DEANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
H. I. S.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1396292918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2230 W. GRANDE BLVD., SUITE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-567-0028
Provider Business Mailing Address Fax Number:
903-567-0029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 E. DALLAS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-567-0028
Provider Business Practice Location Address Fax Number:
903-567-0029
Provider Enumeration Date:
09/01/2016

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: 237700000X , with the licence number:  11328 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: 80689 , 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)





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