Basic Information
| Provider Information | |||||||||
| NPI: | 1396745758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEEDS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18780 INTERSTATE 20 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751033593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035674841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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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 | 1500540 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 10117 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA03575 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8J89591YMAF | 01 | TX | MEDICARE | OTHER | 201289001 | 05 | TX | MEDICAID | 8Y2333 | 01 | TX | BCBS | OTHER | 100454690A | 05 | KS | MEDICAID |