Basic Information
| Provider Information | |||||||||
| NPI: | 1629459623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASFAR | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RUSTON | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3025 N TARRANT PKWY STE 220 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761778629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176973900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3025 N TARRANT PKWY STE 220 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761778629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178857827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 04/23/2019 | ||||||||
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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 | PA09962 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8392NU | 01 | TX | BCBS | OTHER | 355584901 | 05 | TX | MEDICAID |