Basic Information
| Provider Information | |||||||||
| NPI: | 1376556019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AWTREY | ||||||||
| FirstName: | STATON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4214 ANDREWS HWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797034817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326866600 | ||||||||
| FaxNumber: | 4326822284 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 ROSALIND REDFERN GROVER PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797015852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4322212107 | ||||||||
| FaxNumber: | 4322215218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | H6019 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208G00000X | H6019 | TX | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 147713503 | 01 | TX | MEDICAID - MIDLAND - PFC | OTHER | 8663J0 | 01 | TX | BCBS AUSTIN ID NUMBER | OTHER | 8663JO | 01 | TX | MEDICARE PIN SAN ANGELO | OTHER | TXB138584 | 01 | TX | TX MEDICARE-PREMIER | OTHER | 85010X | 01 | TX | BCBS SAN ANGELO ID NUMBER | OTHER | TXB138584 | 01 | TX | MIDLAND MEDICARE NUMBER | OTHER | 147713501 | 05 | TX | MEDICAID |