Basic Information
| Provider Information | |||||||||
| NPI: | 1063607398 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TREPA PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TOMBALL REGIONAL EMERGENCY PHYSICIAN ASSOCIATES PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5400 MARYLAND WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159799453 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 605 HOLDERRIETH BLVD | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773756445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814017500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLASCHKE | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | GLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6159799453 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0057QC | 01 | TX | BCBS | OTHER | 190652101 | 05 | TX | MEDICAID |