1649309410 NPI number — JONATHAN R REDWING PA-C

Table of content: JONATHAN R REDWING PA-C (NPI 1649309410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649309410 NPI number — JONATHAN R REDWING PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDWING
Provider First Name:
JONATHAN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1649309410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3414 GOLDEN RD
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:
75701-8336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-939-7500
Provider Business Mailing Address Fax Number:
903-939-7728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3414 GOLDEN RD
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:
75701-8336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-939-7500
Provider Business Practice Location Address Fax Number:
903-939-7728
Provider Enumeration Date:
03/05/2007

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: 363AS0400X , with the licence number:  PA20070012 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA07915 , 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: 10034669 . This is a "CIGNA/LOVELACE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: P00465646 . This is a "RAILROAD MCEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 80203361 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00NM00RL61 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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