Basic Information
| Provider Information | |||||||||
| NPI: | 1164790721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SKINNER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035938441 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2011 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 8108ND | 01 | TX | BCBS | OTHER | 288707703 | 05 | TX | MEDICAID | 75-0818167-015 | 01 | TX | TRICARE | OTHER | 288707707 | 05 | TX | MEDICAID | 75-0818167-048 | 01 | TX | TRICARE | OTHER | 75-0818167-044 | 01 | TX | TRICARE | OTHER | P01276462 | 01 | TX | RAIL ROAD | OTHER | 288707705 | 05 | TX | MEDICAID | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 8107ND | 01 | TX | BCBS | OTHER | 288707704 | 05 | TX | MEDICAID | 288707706 | 05 | TX | MEDICAID | 75-0818167-022 | 01 | TX | TRICARE | OTHER | 75-2616977-129 | 01 | TX | TRICARE | OTHER | 8808NA | 01 | TX | BCBS | OTHER | P01200590 | 01 | TX | RAIL ROAD | OTHER | 75-1976930-005 | 01 | TX | TRICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | P01200614 | 01 | TX | RAIL ROAD | OTHER |