Basic Information
Provider Information | |||||||||
NPI: | 1336530633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VERA | ||||||||
FirstName: | GEORGE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 749 | ||||||||
Address2: |   | ||||||||
City: | PHARR | ||||||||
State: | TX | ||||||||
PostalCode: | 785771614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9563789290 | ||||||||
FaxNumber: | 9563789376 | ||||||||
Practice Location | |||||||||
Address1: | 1601 E SPRAGUE ST | ||||||||
Address2: |   | ||||||||
City: | EDINBURG | ||||||||
State: | TX | ||||||||
PostalCode: | 78542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9563789290 | ||||||||
FaxNumber: | 9563789376 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2015 | ||||||||
LastUpdateDate: | 08/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA09605 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 514409ZT6L | 01 | TX | WELLMED PTAN | OTHER | 360074401 | 05 | TX |   | MEDICAID |