Basic Information
Provider Information | |||||||||
NPI: | 1558722827 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALAS | ||||||||
FirstName: | JASMIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1309 HICKORY ST | ||||||||
Address2: |   | ||||||||
City: | ABILENE | ||||||||
State: | TX | ||||||||
PostalCode: | 796013509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3254809280 | ||||||||
FaxNumber: | 3254002007 | ||||||||
Practice Location | |||||||||
Address1: | 1124 N WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | SHELBY | ||||||||
State: | NC | ||||||||
PostalCode: | 281503862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9804871148 | ||||||||
FaxNumber: | 7044877753 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2016 | ||||||||
LastUpdateDate: | 02/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 0010-06347 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X | PA12250 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1558722827 | 05 | NC |   | MEDICAID | 2609PA | 05 | SC |   | MEDICAID |